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THE PRINCIPLES AND 
PRACTICE OF MEDICINE 



DESIGNED FOR THE USE OF PRACTITIONERS 
AND STUDENTS OF MEDICINE 



Fellow of the Royal Society ; Fellow of the Royal College of Physicians, 
London ; Professor of Medicine in the Johns Hopkins University and 
Physician-in-chief to the Johns Hopkins Hospital, Baltimore ; 
formerly Professor of the Institutes of Medicine, McGill 
University, Montreal ; and Professor of Clinical Medicine 
in the University of Pennsylvania, Philadelphia 



BY 



WILLIAM OSLER, M. D. 




D. 



NEW YORK 
APPLETON AND COMPANY 
1901 



THE LIBRARY OF 

CONGRESS, 
Two CoH&J Received 

SEP. 25 1901 

-Copyright entry 
CLASS ^ XX& N*. 
COPY a 



Copyright, 1892, 1895, 1898, 1901, 
By D. APPLETON AND COMPANY. 



LC Control Number 




tmp96 029097 



TO THE 

Jttemorji of mr\ QHcat^exs: 
WILLIAM ARTHUR JOHNSON, 

PRIEST OF THE PARISH OF WESTON, ONTARIO. 

JAMES BOVELL, 

OF THE TORONTO SCHOOL OF MEDICINE, AND OF THE 
UNIVERSITY OF TRINITY COLLEGE, TORONTO. 

ROBERT PALMER HOWARD, 

DEAN OF THE MEDICAL FACULTY AND PROFESSOR OF MEDICINE, 
MC GILL UNIVERSITY, MONTREAL. 



PREFACE TO THE FOURTH EDITION. 



Many and important changes have been made in this edition. The 
article on Typhoid Fever has been in great part rewritten, and there is 
embodied in it the additional experience of my clinic. The subject of 
malaria has had to be recast, and the important new matter on etiology 
and prophylaxis has been added. Dysentery, Yellow Fever, and the Plague 
have attracted the attention of so many workers that it is difficult to keep 
pace with the rapid progress of our knowledge. I have tried to bring 
these articles up to date, and in rewriting them have kept in mind the 
needs of physicians practicing in the tropics. On the all-important dis- 
ease, Pneumonia, the student will find many new paragraphs. I have 
incorporated in the article on Diphtheria the model work which has been 
done by McCollum and by Councilman and his colleagues at the Boston 
City Hospital. On Small-pox, Cerebro-spinal Fever, Eheumatic Fever, and 
many others of the acute infections, new points are added on diagnosis 
and treatment. 

Dr. Futcher, my first assistant, has analyzed for this edition the ex- 
perience of my clinic for the past twelve years on Diabetes and Gout, in 
which sections much new matter has been incorporated. The sections on 
Obesity and Arthritis Deformans have been changed. 

Practically new articles, in whole or in part, are those on Acute Tuber- 
culosis, Diseases of the Pancreas, Splenic Ana?mia, Arsenical Poisoning, 
Herpes Zoster, Adiposis Dolorosa, Fibrinous Bronchitis, Albumosuria. 
Oxaluria, Meniere's Disease, Aphasia, Combined Sclerosis of the Cord, 
Myasthenia Gravis, Congenital Aneurism, Surgical Treatment of Aneurism 
and Scurvy. 

Dr. McCrac has analyzed for this edition the material of the clinic on 
Pernicious Anamria and Leuksemia. 

Minor changes, too numerous to mention, have been incorporated, and 
my aim has been to deserve — and, if possible, to repay in some slight meas- 

v 



vi 



PREFACE TO THE FOURTH EDITION. 



nre — the confidence which the profession has shown in the previous edi- 
tions of the work. 

I have again to thank many friends for valuable help — my colleague, 
Dr. W. H. Welch, whom I have consulted on many questions; Dr. H. M. 
Thomas, for a revision of the article on Aphasia, and for many additions 
in the section on the Nervous System; my associates and assistants, Drs. 
Thayer, Futcher, McCrae, T. E. Brown, L. P. Hamburger, and Bufus Cole, 
for much important aid; Dr. Simon Flexner, now of the University of 
Pennsylvania, for information upon the forms of Dysentery; Drs. W. G. 
MacCallum and E. L. Opie, for notes from the Pathological Department. 

To friends too numerous to mention I am very grateful for memoranda, 
pointing out errors or making suggestions — two I must mention by name, 
H. D. Bolleston and George Blumer. 

In passing through the press the work has again had the advantage 
of the supervision of Dr. F. E. Smith. To my secretary, Miss B. 0. 
Humpton, I am indebted for constant help in the preparation of the edi- 
tion and for the revision of the index. 

AYlLLIAM OSLEK. 

July 1, 1901. 



CONTENTS. 



SECTION I. 
SPECIFIC INFECTIOUS DISEASES. 

PAGE 

I. Typhoid Fever 1 

II. Typhus Fever 49 

III. Relapsing Fever 53 

IV. Small-pox 56 

Variola Vera 59 

Hemorrhagic Small-pox 62 

Varioloid . . . '. .63 

V. Vaccinia (Cow-pox) — Vaccination . 68 

VI. Varicella (Chicken-pox) 74 

VII. Scarlet Fever 75 

VIII. Measles 85 

IX. Rubella (Rotheln) 89 

X. Epidemic Parotitis (Mumps) 90 

XI. Whooping-cough 92 

XII. Influenza 95 

XIII. Dengue 99 

XIV. Cerebro-spinal Fever 100 

XV. Pneumonia .... 108 

XVI. Diphtheria 138 

XVII. Erysipelas 157 

XVIII. Septicaemia and Pyaemia 160 

Septicaemia 161 

Septico-Pyaemia . 163 

Terminal Infections ...„„... 165 

XIX. Rheumatic Fever ............ 166 

XX. Cholera Asiatica 175 

XXI. Yellow Fever 182 

XXII. The Plague 189 

XXIII. Dysentery . 193 

XXIV. Malarial Fever . . . . . ; 203 

Intermittent Fever 209 

Continued and Remittent Malarial Fever . 213 

Pernicious Malarial Fever 215 

Malarial Cachexia 2 16 

XXV. Malta Fever 219 

XXVI. Beri-beri 220 

XXVII. Anthrax 224 

XXVIII. Hydrophobia '207 

XXIX. Tetanus 230 

XXX. Glanders ..... 0 ........ 233 

vii 



viii CONTENTS. 

PAGE 

XXXI. Actinomycosis. . 235 

XXXII. Syphilis 238 

Acquired 240 

Congenital 242 

Visceral 244 

XXXIII. Gonorrhoeal Infection 255 

XXXIV. Tuberculosis 258 

1. General Etiology and Morbid Anatomy 258 

2. Acute Tuberculosis . 273 

3. Tuberculosis of the Lymphatic System 280 

4. " of the Lungs (Phthisis, Consumption) .... 289 

5. " of the Alimentary Canal 317 

6. " of the Liver 320 

7. " of the Brain and Spinal Cord 321 

8. " of the Genito-urinary System 322 

9. " of the Mammary Gland 327 

10. " of the Circulatory System 327 

11. Diagnosis of Tuberculosis . 328 

12. Prognosis in Tuberculosis 328 

13. Prophylaxis in Tuberculosis . . . 330 

14. Treatment of Tuberculosis 331 

XXXV. Leprosy 338 

XXXVI. Infectious Diseases of Doubtful Nature 342 

1. Febricula (Ephemeral Fever) 342 

2. Weil's Disease . . . . .344 

3. Milk-sickness 344 

4. Glandular Fever 345 

5. Mountain Fever 346 

6. Miliary Fever (Sweating Sickness) 346 

7. Foot and Mouth Disease . .347 

SECTION II. 
DISEASES DUE TO ANIMAL PARASITES. 

I. Psorospermiasis 349 

1. Internal Psorospermiasis 349 

2. Cutaneous Psorospermiasis . ■ 350 

II. Parasitic Infusoria 351 

III. Distomiasis ... . . 351 

IV. Diseases caused by Nematodes . . 352 

1. Ascariasis 352 

2. Trichiniasis . . . . 354 

3. Ankylostomiasis 359 

4. Filariasis ' 360 

5. Dracontiasis 362 

6. Other Nematodes { 364 

Acanthocephala 365 

V. Diseases caused by Cestodes . 365 

1. Intestinal Cestodes ; Tape-worms 365 

2. Visceral Cestodes 368 

Cysticercus Cellulosse . 368 

Echinococcus Disease . 370 

Multilocular Echinococcus , . 374 



CONTENTS. ix 

PAGE 

VI. Parasitic Arachnida 375 

VII. Parasitic Insects 376 

VIII. Myiasis . . . . 378 

SECTION III. 
THE INTOXICATIONS AND SUN-STROKE. 

I. Alcoholism 380 

1. Acute Alcoholism 380 

2. Chronic Alcoholism 380 

3. Delirium Tremens . . .382 

II. Morphia Habit 384 

III. Lead Poisoning 386 

IV. Arsenical Poisoning 390 

V. Food Poisoning . . 391 

1. Meat Poisoning 391 

2. Poisoning by Milk Products 393 

3. Poisoning by Shell-fish and Fish 393 

4. Grain Poisoning 394 

VI. Sun-stroke . . . . . 395 

SECTION IV. 

CONSTITUTIONAL DISEASES. 

I. Arthritis Deformans 399 

II. Chronic Rheumatism 405 

III. Muscular Rheumatism 406 

IV. Gout 407 

V. Diabetes Mellitus 418 

VI. Diabetes Insipidus 432 

1 VII. Rickets 434 

VIII. Obesity 439 

SECTION V. 

DISEASES OF THE DIGESTIVE SYSTEM. 

I. Diseases of the Mouth 441 

Stomatitis . » 441 

Aphthous Stomatitis 441 

Ulcerative Stomatitis 442 

Parasitic Stomatitis (Thrush) 443 

Gangrenous Stomatitis 444 

Mercurial Stomatitis 444 

Eczema of the Tongue 445 

Leukoplakia buccalis 446 

II. Diseases of the Salivary Glands . 446 

Supersecretion . 446 

Xerostomia 447 

Inflammation of the Salivary Glands 447 

III. Diseases of the Pharynx 448 

Circulatory Disturbances 448 

Acute Pharyngitis 448 

Chronic Pharyngitis 449 



X 



CONTENTS. 



PAGE 

Ulceration of the Pharynx 449 

Acute Infectious Phlegmon of the Pharynx . . . . . . 450 

Retro-pharyngeal Abscess . . . 450 

Angina Ludovici 450 

IV. Diseases of the Tonsils 451 

Acute Tonsillitis •. . 451 

Follicular or Lacunar Tonsillitis 451 

Suppurative Tonsillitis 452 

Chronic Tonsillitis 454 

V. Diseases of the (Esophagus 458 

Acute Oesophagitis 458 

Spasm of the (Esophagus 459 

Stricture of the (Esophagus 460 

Cancer of the (Esophagus 461 

Rupture of the (Esophagus 462 

Dilatations and Diverticula 462 

VI. Diseases of the Stomach 463 

Acute Gastritis 463 

Phlegmonous Gastritis 464 

Toxic Gastritis 465 

Diphtheritic Gastritis 465 

Mycotic Gastritis 466 

Chronic Gastritis (Chronic Dyspepsia) 466 

Dilatation of Stomach 474 

Peptic Ulcer (Gastric and Duodenal) 478 

Cancer of Stomach 486 

Hypertrophic Stenosis of the Pylorus 494 

Haemorrhage from the Stomach . . 495 

Neuroses of the Stomach 497 

VII. Diseases of the Intestines 505 

1. Diseases of the Intestines associated with Diarrhoea 505 

Catarrhal Enteritis : Diarrhoea 505 

Enteritis in Children 508 

Diphtheritic or Croupous Enteritis 512 

Phlegmonous Enteritis 512 

Ulcerative Enteritis 512 

2. Appendicitis (Typhlitis and Perityphlitis) 519 

3. Intestinal Obstruction . . . . . 531 

4. Constipation (Costiveness) . 538 

5. Enteroptosis (Glenard's Disease) ■ „ . 541 

6. Miscellaneous Affections 544 

Mucous Colitis 544 

Dilatation of the Colon 545 

Intestinal Sand . 546 

Affections of the Mesentery 546 

VIII. Diseases of the Liver 548 

1. Jaundice (Icterus) 548 

2. Icterus Neonatorum 551 

3. Acute Yellow Atrophy 551 

4. Affections of the Blood-vessels of the Liver 553 

5. Diseases of the Bile-passages and Gall-bladder 555 

6. Cholelithiasis 561 

7. Cirrhoses of the Liver 569 

8. Abscess of the Liver ...» 577 



CONTENTS. xj 

PAGE 

9. New Growths in the Liver 582 

10. Fatty Liver . . . . 585 

11. Amyloid Liver 586 

12. Anomalies in Form and Position of the Liver 587 

IX. Diseases of the Pancreas 588 

1. Haemorrhage 588 

2. Acute Pancreatitis 589 

3. Chronic Pancreatitis 592 

4. Pancreatic Cysts 592 

5. Tumors of the Pancreas , . . 594 

6. Pancreatic Calculi 595 

X. Diseases of the Peritonaeum 596 

1. Acute General Peritonitis . 596 

2. Peritonitis in Infants . 600 

3. Localized Peritonitis . . . . 600 

4. Chronic Peritonitis . . 602 

5. New Growths in the Peritonaeum 604 

6. Ascites (Hydro-peritonaeum) 605 

SECTION VI. 

DISEASES OF THE RESPIRATORY SYSTEM. 

I. Diseases of the Nose 610 

Acute Coryza 610 

Chronic Nasal Catarrh 611 

Autumnal Catarrh (Hay Fever) 612 

Epistaxis 614 

II. Diseases of the Larynx 615 

1. Acute Catarrhal Laryngitis 615 

2. Chronic Laryngitis 616 

3. (Edematous Laryngitis 617 

4. Spasmodic Laryngitis (Laryngismus stridulus) 617 

5. Tuberculous Laryngitis s 619 

6. Syphilitic Laryngitis 620 

III. Diseases of the Bronchi 621 

1. Acute Bronchitis 621 

2. Chronic Bronchitis 623 

3. Bronchiectasis , 626 

4. Bronchial Asthma 628 

5. Fibrinous Bronchitis 632 

IV. Diseases of the Lungs 634 

1. Circulatory Disturbances in the Lungs 634 

2. Broncho-pneumonia (Capillary Bronchitis) 641 

3. Chronic Interstitial Pneumonia (Cirrhosis of Lung) 649 

4. Pneumonokoniosis ; 652 

5. Emphysema . . . . , , 654 

Compensatory Emphysema 655 

Hypertrophic Emphysema 655 

Atrophic Emphysema 659 

Acute Vesicular Emphysema 660 

Interstitial Emphysema 660 

6. Gangrene of the Lung 660 

7. Abscess of the Lung 662 

8. New Growths in the Lungs GOD 



xii CONTENTS. 

PAGE 

V. Diseases of the Pleura 665 

1. Acute Pleurisy . 665 

Fibrinous or Plastic Pleurisy 665 

Sero-fibrinous Pleurisy . 666 

Purulent Pleurisy (Empyema) 671 

Tuberculous Pleurisy 673 

Other Varieties of Pleurisy 673 

2. Chronic Pleurisy , . .678 

3. Hydrothorax 680 

4. Pneumothorax (Hydro-pneumothorax and Pyo-pneumothorax) . . . 681 

5. Affections of the Mediastinum . . . . . . . . 684 

SECTION VII. 
DISEASES OF THE CIRCULATORY SYSTEM. 

I. Diseases of the Pericardium 688 

1. Pericarditis . . 688 

2. Other Affections of the Pericardium . . . ' 697 

II. Diseases of the Heart . 698 

1. Endocarditis 698 

Acute Endocarditis 698 

Chronic Endocarditis 705 

2. Chronic Valvular Disease 707 

General Introduction 707 

Aortic Incompetency , . . 709 

Aortic Stenosis . . . . 715 

Mitral Incompetency . . .717 

Mitral Stenosis 721 

Tricuspid Valve Disease . 725 

Pulmonary Valve Disease . . . 727 

Combined Valvular Lesions 728 

3. Hypertrophy and Dilatation 735 

Hypertrophy of the Heart 735 

Dilatation of the Heart 741 

4. Affections of the Myocardium , • . . 746 

Aneurism of the Heart 753 

Rupture of the Heart 753 

New Growths and Parasites 754 

Wounds and Foreign Bodies 754 

5. Neuroses of the Heart 755 

Palpitation . . . . . 755 

Arrhythmia 756 

Rapid Heart (Tachycardia) - . 758 

Slow Heart (Bradycardia) 759 

Angina Pectoris . . . . 761 

6. Congenital Affections of the Heart 765 

III. Diseases of the Arteries 770 

1. Degenerations 770 

2. Arterio-sclerosis (Arterio-capillary Fibrosis) 770 

3. Aneurism . 776 

Aneurism of the Thoracic Aorta 777 

Aneurism of the Abdominal Aorta 786 

Aneurism of the Branches of the Abdominal Aorta 787 



CONTENTS. xiii 

PAGE 

Arteriovenous Aneurism . 788 

Congenital Aneurism 788 

SECTION VIII. 

DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 

I. Anaemia . . • . . . . . 789 

Secondary Anaemia J 789 

Primary or Essential Anaemia 792 

II. Leukaemia . . . . . . . . . . . . . .802 

III. Hodgkin's Disease 809 

IV. Purpura 814 

V. Haemophilia . .819 

VI. Scurvy . 821 

VII. Status Lymphaticus 826 

VIII. Diseases of the Suprarenal Bodies . 828 

IX. Diseases of the Spleen 832 

X. Diseases of the Thyroid Gland 835 

Goitre 835 v 

Tumors of the Thyroid 836 

Exophthalmic Goitre 836 

Myxcedema 840 

XI. Diseases of the Thymus Gland 843 

SECTION IX. 

DISEASES OF THE KIDNEYS. 

I. Malformations . 846 

II. Movable Kidney 846 

III. Circulatory Disturbances 849 

IV. Anomalies of the Urinary Secretion 850 

1. Anuria 850 

2. Haematuria 851 

3. Haemoglobinuria _ 852 

4. Albuminuria . 854 

5. Pyuria (Pus in the Urine) . . . ' 868 

6. Chyluria (Non-parasitic) 859 

7 Lithuria 859 

8. Oxaluria 861 

9. Cystinuria 861 

10 Phosphaturia ... 862 

11. Indicanuria 863 

12. Melanuria 863 

13. Pneumaturia .... 864 

14. Other Substances . 864 

. V. Uraemia . . . . ' 865 

VI. Acute Bright's Disease ' . 869 

VII. Chronic Bright's Disease . . 874 

Chronic Parenchymatous Nephritis 875 

Chronic Interstitial Nephritis 877 

VIII. Amyloid Disease 884 

IX. Pyelitis 886 

X. Hydronephrosis , 889 



xiv CONTENTS. 

PAGE 

XI. Nephrolithiasis (Renal Calculus) . .891 

XTI. Tumors of the Kidney 896 

XIII. Cystic Disease of the Kidney 898 

XIV. Perinephric Abscess 900 

SECTION X. 

DISEASES OF THE NERVOUS SYSTEM. 

I. General Introduction 901 

II. System Diseases 919 

1. Introduction 919 

2. Diseases of the Afferent or Sensory System 920 

Locomotor Ataxia . . . 920 

3. Diseases of the Efferent or Motor Tract 928 

Of the Whole Tract 928 

Progressive (Central) Muscular Atrophy 928 

Bulbar Paralysis . .932 

Progressive Neural Muscular Atrophy 933 

The Muscular Dystrophies 933 

System Diseases of the Upper Motor Segment 936 

Spastic Paralysis of Adults • . . 937 

Spastic Paralysis of Infants 938 

Hereditary Spastic Paraplegia 940 

Erb's Syphilitic Spinal Paralysis 940 

Secondary Spastic Paralysis 941 

Hysterical Spastic Paraplegia 941 

System Diseases of the Lower Motor Segment 941 

Chronic Anterior Polio-myelitis 941 

Ophthalmoplegia 942 

Acute Anterior Polio-myelitis 942 

Acute and Subacute Polio-myelitis in Adults ..... 946 

Acute Ascending (Landry's) Paralysis 946 

Myasthenia Gravis 947 

4. Combined System Diseases 947 

Ataxic Paraplegia . . . . . . . . . . 948 

Primary Combined Sclerosis (Putnam) 949 

Hereditary Ataxia (Friedreich's Ataxia) 949 

Progressive Interstitial Hypertrophic Neuritis of Infants . . . 951 

Toxic Combined Sclerosis 951 

III. Diffuse Diseases of the Nervous System 951 

1. Affections of the Meninges 951 

Diseases of the Dura Mater (Pachymeningitis) 951 

Hemorrhagic Pachymeningitis . . - 952 

Diseases of the Pia Mater . . . . . . . . 954 

Simple Meningitis of Infants 957 

2. Scleroses of the Brain 957 

Insular Sclerosis . . . 959 

3. Chronic Diffuse Meningoencephalitis . . . . . . . 960 

IV. Diffuse and Focal Diseases of the Spinal Cord 964 

1. Topical Diagnosis 964 

2. xVffections of the Blood-vessels 966 

Congestion . . 966 

Anaemia 966 

Embolism and Thrombosis 966 



CONTENTS. 



XV 



PAGE 

Endarteritis 96" 

Haemorrhage into the Spinal Membranes 96 r 

Haemorrhage into the Spinal Cord 968 

Caisson Disease 969 

3. Compression of the Spinal Cord 970 

Lesions of the Cauda Equina and Conus Medullaris .... 972 

4. Tumors of the Spinal Cord and its Membranes 973 

5. Syringomyelia . b . . . . . 97o 

6. Acute Myelitis . . . 976 

V. Diffuse and Focal Diseases of the Brain 979 

1. Topical Diagnosis 979 

2. Aphasia 988 

3. Affections of the Blood-vessels ......... 994 

Hyperaemia 994 

Anaemia 995 

(Edema of the Brain . . .99 

Cerebral Haemorrhage 99 r 

Embolism and Thrombosis 1008 

Aneurism of the Cerebral Arteries 1013 

Endarteritis 1014 

Thrombosis of the Cerebral Sinuses and Veins 101; 

Hemiplegia in Children . . . 101 

4. Tumors, Infectious Granulomata, and Cysts of the Brain . . . 1020 

5. Inflammation of the Brain 1024 

Acute Encephalitis .* . 1024 

Abscess of the Brain 1025 

6. Hydrocephalus . , ' 1028 

VI. Diseases of the Peripheral Nerves 1031 

1. Neuritis (Inflammation of the Bundles of Nerve Fibres) . . . . 1031 

2. Neuromata . . • . ... . . 103" 

3. Diseases of the Cerebral Nerves . . . . . . . . 1038 

Olfactory Nerves and Tracts 1038 

Optic Nerve and Tract 1039 

Lesions of the Retina 1039 

Lesions of the Optic Nerve 1040 

Affections of the Chiasma and Tract 1041 

Affections of the Tract and Centres 1042 

Motor Nerves of the Eyeball 1045 

Fifth Nerve 1050 

Facial Nerve 1051 

Auditory Nerve 1056 

The Cochlear Nerve 1056 

The Vestibular Nerve 1058 

Glossopharyngeal Nerve 1059 

Pneumogastric Nerve 1060 

Spinal Accessory 1063 

Hypoglossal Nerve 1066 

4. Diseases of the Spinal Nerves 106' 

Cervical Plexus 106 

Brachial Plexus 1069 

Lumbar and Sacral Plexuses 1071 

Sciatica 107; 

VII. General and Functional Diseases 107; 

1. Acute Delirium (Bell's Mania) 1074 

B 



xvi ' CONTENTS. 

PAGE 

2. Paralysis Agitans . . . . 1076 

Other Forms of Tremor 1079 

3. Acute Chorea (Sydenham's Chorea ; St. Vitus's Dance) .... 1079 

4. Other Affections described as Chorea 1088- 

5. Infantile Convulsions (Eclampsia) . ' . . . . . . 1091 

6. Epilepsy . ' . . . . . . . . . . . . 109a 

7. Migraine . . . . 1102 

8. Neuralgia 1104 

9. Professional Spasms ; Occupation Neuroses . . . ... 1107 

10. Tetany 1109 

11. Hysteria 1111 

12. Neurasthenia • 1122 

13. The Traumatic Neuroses 1132 

14. Other Forms of Functional Paralysis 1136 

Periodical Paralysis 1136 

Astasia; Abasia . 1136 

VIII. Vaso-motor and Trophic Disorders 1137 

1. Raynaud's Disease 1137 

2. Erythromelalgia 1139 

3. Angio-neurotic (Edema ' 1140 

4. Facial Hemiatrophy 1141 

5. Acromegaly 1142- 

Osteitis Deformans 1144 

Hypertrophic Pulmonary Arthropathy 1144 

Leontiasis Ossea • '. . . . . 1145 

Micromegaly 1145 

6. Scleroderma 1145 

Ainhum . . . . . 1147 

SECTION XI. 
DISEASES OF THE MUSCLES. 

I. Myositis 114& 

II. Myotonia (Thomsen's Disease) 1149 

III. Paramyoclonus Multiplex , 1150» 



CHAETS AND ILLUSTRATIONS. 



CHART PAGE 

I. Typhoid Fever with Relapse 15 

II. Illustrating the Blood Changes in Typhoid Fever 20 

III. Typhoid Fever — Haemorrhage from the Bowels * . . . . . . . 24 

IV. Illustrating Influence of Baths in Typhoid Fever 44 

V. Relapsing Fever (after Murchison) 55 

VI. Small-pox (after Strumpell) 60 

VII. Scarlet Fever .'. ' 78 

VIII. Measles 86 

IX. Temperature, Pulse, and Respiration Chart in Pneumonia .... 116 
X. Showing Coincident Drop in the Fever and in the Leucocytes in Pneu- 
monia 121 

XI a. Malaria — Double Tertian Infection — Quotidian Fever .... 210 

XI b. iEstivo-autumnal Infection — Remittent Fever 210 

XI c. iEstivo-autumnal Fever — Quotidian Paroxysms . . . . . 211 

XI d. Quartan Fever . 211 

XII. Chronic Tuberculosis, Two-hourly Chart for Three Days .... 305 

XIII. Case of Sun-stroke treated with Ice-bath. Recovery. (Rectal Tempera- 

tures) 397 

XIV. Showing Uric Acid and Phosphoric Acid Output in a Case of Acute Gout . 412 
XV. Illustrating Influence of Diet on Sugar and Amount of Urine in Diabetes . 430 

XVI. Diagrams after Martius, showing schematically the Power of the Heart 

Muscle 708 

XVII. Blood Chart, illustrating Anaemia in Purpura Hemorrhagica . . . 790 

XVIII. Blood Chart, illustrating Chlorosis 793 

XIX. Blood Chart, illustrating Pernicious Anosmia 798 

XX. Blood Chart, illustrating Leukaemia 807 

XXI. Blood Chart, illustrating Rapid Production of Anaemia in Purpura Haem- 

orrhagica .817 

FIGURE 

1. Diagram of Motor Path (Van Gehuchten) 903 

2. Diagram of Motor Path from Right Brain (Van Gehuchten) . . .904 

3. Diagram of Cerebral Localization 907 

4. Diagram of Motor and Sensory Representation in the Internal Capsule . 908 

5. Diagram of Motor and Sensory Paths in Crura 909 

6. Diagram of Cross-section of Spinal Cord 909 

7, 8. Head's Diagrams of Skin Areas corresponding to the Different Spinal 

Segments 910,911 

10. Diagram of Motor Path from Right Brain 1003 

II. Diagram of Visual Paths (Vialet) 1043 



* The red shows the two-hourly, the black the morning and evening temperature, 

xv ii 



" Experience is fallacious and judgment difficult." 

Hippocrates : Aphorisms, I. 

" And I said of medicine, that this is an art which 
considers the constitution of the patient, and has 
principles of action and reasons in each case." 

Plato: G-orgias. 



A TEXT-BOOK ON 
THE PRACTICE OF MEDICINE. 



SECTION I. 

SPECIFIC INFECTIOUS DISEASES. 

I. TYPHOID FEVER. 

Definition. — A general infection caused by bacillus typhosus, charac- 
terized anatomically by hyperplasia and ulceration of the lymph-follicles 
of the intestines, swelling of the mesenteric glands and spleen, and paren- 
chymatous changes in the other organs. While these lesions are almost 
constant, there are cases in which the local changes are slight or absent, 
and there are others with intense localization of the poison in the lungs, 
spleen, kidneys, or cerebro-spinal system. Clinically the disease is marked 
by fever, a rose-colored eruption, diarrhoea, abdominal tenderness, tym- 
panites, and enlargement of the spleen; but these symptoms are extremely 
inconstant, and even the fever varies in its character. 

Historical Note. — Huxham, in his remarkable Essay on Fevers, had 
" taken notice of the very great difference there is between the putrid 
malignant and the slow nervous fever." In 1813 Pierre Bretonneau, of 
Tours, distinguished " dothienenterite " as a separate disease; and Petit 
and Serres described entero-mesenteric fever. In 1829 Louis' great work 
appeared, in which the name " typhoid " was given to the fever. At this 
period typhoid fever alone prevailed in Paris, and it was universally be- 
lieved to be identical with the continued fever of Great Britain, where 
in reality typhoid and typhus coexisted; and the intestinal lesion was 
regarded as an accidental occurrence in the course of ordinary typhus. 
Louis' students returning to their homes in different countries had oppor- 
tunities for studying the prevalent fevers in the thorough and systematic 
manner of their master. Among these were certain young American 
physicians, to one of whom, Gerhard, of Philadelphia, is due the greal 
honor of having first clearly laid down the differences between the two 
diseases. His papers in the American Journal of the Medical Sciences, 
1837, are the first which give a full and satisfactory account of their clinical 
and anatomical distinctions. The studies of James Jackson, Sr. and Jr., 
of Enoch Hale and of George C. Shattuck, of Boston, and of Alfred Still* 
and Austin Flint made the subject very familiar in American medicine. 
1 1 



2 



SPECIFIC INFECTIOUS DISEASES. 



In 1842 Elisha Bartlett's work appeared, in which, for the first time in 
a systematic treatise, typhoid and typhus fever were separately considered 
with admirable clearness. In Great Britain the recognition of the differ- 
ence between the two diseases was very slow, and was due largely to 
A. P. Stewart, of Glasgow, and, finally, to the careful studies of Jenner 
between 1849 and 1850. 

Etiology. — General Prevalence. — Typhoid fever prevails especially in 
temperate climates, in which it constitutes the most common continued 
fever. Widely distributed throughout all parts of the world, it probably 
presents everywhere the same essential characteristics, and is everywhere 
an index of the sanitary intelligence of a community. Defective drainage 
and contaminated water supply are the two special conditions favoring 
the distribution and growth of the bacilli; filth, overcrowding, and bad 
ventilation are accessories in lowering the resistance of the individuals 
exposed. 

While improved sanitation has done much to reduce the mortality from 
typhoid fever, particularly in the large cities, a reduction amounting to 
45.4 per cent in 21 out of 24 English towns (Dreschfeld) (figures illustrat- 
ing which will be referred to under Prophylaxis), the disease is still far too 
prevalent, and in suburban and rural districts in this country there is 
evidence to show that it is on the increase. In 1890 the death-rate from 
typhoid fever per 100,000 of population was, in the United States, 46.27; 
in England and Wales, 17.9; in Italy, 65.8; in Austria, 47.0; and in Prus- 
sia, 20.4. 

Since the last edition of this work was issued (1898) there have been 
three great object lessons in typhoid fever. 

(a) The Spanish- American War. — According to the report of the Com- 
mission, consisting of Walter Reed, Victor C. Vaughan, and Edward O. 
Shakespeare, one fifth of the soldiers in the national encampments in 
the United States had typhoid fever. Among 107,973 men there were 
20,738 cases — 19.26 per cent. In 90 per cent of the volunteer regiments 
the disease broke out within eight weeks of going into camp. The Com- 
mission points out that typhoid fever is so widely distributed in this 
country that cases are likely to appear in any regiment within a few 
Weeks after organization. So universal is the disease that in all modern 
campaigns it has usually appeared within two months, and has proved the 
most fatal of camp diseases. The deaths from typhoid fever were 86.24 
per cent of the total deaths. Camp pollution, flies as carriers of con- 
tagion, the transportation of the poison in the clothing, the dissemination 
of infection through the air in the form of dust were, in the opinion of 
the Commission, the important factors in the widespread prevalence of 
the disease. 

(b) The Philadelphia Epidemic of 1898-99. — Philadelphia, a city of 
1,300,000 inhabitants, gets its water from the Schuylkill and Delaware 
Rivers, the watersheds of which are populous with numerous towns. The 
water is pumped directly into reservoirs, and distributed without filtration. 
In 1897 the total number of cases reported was 2,994, with 401 f deaths. 
In the autumn of 1898 there was a sudden increase, and 1,094 cases were 



TYPHOID FEVER. 



h 



reported in September, due in part, of course, to the influx of soldiers with 
typhoid fever. The total number of cases for the year was 6,097, with 
639 deaths. In the first four months of 1899 there were 5,861 cases 
reported, with 638 deaths. The total for the year was 7,985 cases, with 
948 deaths. 

(c) The South African War. — To end of March, 1901, the official returns 
give for the English army 25,359 cases of enteric or typhoid fever, with 
5,302 deaths. This gives a percentage of 13.09 per 100, in comparison with 
19.26 in the American army, and 31.8 among the Germans before Metz. 
In South Africa, as in America, the disease was essentially one of the 
standing camps; troops constantly on the move were rarely much affected. 
While contaminated water was no doubt an important factor, as it always 
is in camp pollution, yet certain of the conditions of Africa were peculiar. 
Faecal and urinary contamination must have been very common, as in the 
cooking, performed in the open air, sand " entered largely into every article 
of food." As there was a perfect plague of flies, they were no doubt an 
important factor in the infection of both food and drink. The conditions 
in camp life favor the personal infection from man to man. 

Season. — It prevails most in the autumn months. Of 1,889 cases ad- 
mitted to the Montreal General Hospital in twenty years, more than fifty 
per cent were in the months of August, September, and October. Of 829 
cases treated during ten years at the Johns Hopkins Hospital, 460 occurred 
during these months. It has been well called the autumnal fever. It has 
been observed to be especially prevalent in hot and dry seasons. According 
to Pettenkofer, epidemics are most common when the ground-water is low, 
under which circumstances the springs and water-sources drain more thor- 
oughly contaminated foci and are more likely to be highly charged with 
poison. It may be also, as Baumgarten suggests, that in dry seasons the 
poison is more disseminated in the dust. 

Sex. — Males and females are about equally liable to the disease, but 
males with typhoid are much more frequently admitted into hospitals. 

Age. — Typhoid fever is a disease of youth and early adult life. The 
greatest susceptibility is between the ages of fifteen and twenty-five. Of 
829 cases treated to May 15, 1899, in my wards at the Johns Hopkins 
Hospital there were under fifteen years of age, 99; between fifteen and 
twenty, 159; between twenty and thirty, 393; between thirty and forty, 
125; between forty and fifty, 40; between fifty and sixty, 6; above sixty, 
6; age not given, 1.* Cases are rare over sixty, although Manges believes 
that they are more common than the records show. As the course is often 
atypical the diagnosis may be uncertain. In two of my cases the disease 
was not recognized until the autopsy. It is not very infrequent in child- 
hood, but infants are rarely attacked. Murchison saw a case at the sixth 
month. There is no evidence that the disease is congenital even in cases 
in which the mother has contracted it late in pregnancy. 

Immunity. — Not all exposed to the infection take the disease. Some 
families seem more susceptible than others. One attack usually protects. 

* The figures here given are from the Studies on Typhoid Fever, I, II, and III, in vols, 
iv, v, and viii of the Johns Hopkins Hospital Reports. 



4 



SPECIFIC INFECTIOUS DISEASES. 



Two attacks have been described within a year. " Of 2,000 cases of enteric 
fever at the Hamburg General Hospital, only 14 persons were affected twice 
and only 1 person three times" (Dreschfeld). 

Bacillus typhosus. — The researches of Eberth, Koch, Gaffky, and others 
have shown that there is a special micro-organism constantly associated 
with typhoid fever, (a) General Characters. — It is a rather short, thick, 
flagellated, motile bacillus, with rounded ends, in one of which, sometimes 
in both (particularly in cultures), there can be seen a glistening round 
body, at one time believed to be a spore; but these polar structures are 
probably only areas of degenerated protoplasm. It grows readily on various 
nutritive media, and can now be differentiated from bacillus coli com- 
munis, with which, and with certain other bacilli, it is apt to be confounded. 
This organism fulfils two of the requirements of Koch's law — it is con- 
stantly present, and it grows outside the body in a specific manner. The 
third requirement, the production of the disease experimentally by the 
cultures, has not. yet been met. Probably the animals used for experi- 
mentation are not susceptible to typhoid fever. The bacilli or their toxins 
inoculated in large quantities into the blood of rabbits are pathogenic, 
and in some instances ulcerative and necrotic lesions in the intestine may 
be produced. But similar intestinal lesions may be caused by other bac- 
teria, including bacillus coli communis. 

Cultures are killed within ten minutes by a temperature of 60° C. 
They may live for eighteen weeks at — -5° C, although most die within 
two weeks, and all within twenty-two weeks (Park). The typhoid bacillus 
resists ordinary drying for months, unless in very thin layers, when it is 
killed in five to fifteen days. The direct rays of the sun completely destroy 
them in from four to ten hours' exposure. Bouillon cultures are destroyed 
by carbolic acid, 1 to 200, and by corrosive sublimate, 1 to 2,500. 

(b) Distribution in the Body. — In recent typhoid infections the bacilli 
are found in the lymphoid tissues of the intestines, in the mesenteric 
glands, in the spleen, in the bone marrow, in the liver, and in the bile. 
They occur also in irregular clumps in the contents of the intestines and 
in the stools; and since the introduction of improved methods of cultiva- 
tion (Eisner, Piorkowski) they have been demonstrated in the latter in 
about 50 per cent of the cases examined. They may, however, be incapable 
of demonstration even in fatal cases. The bacilli may be demonstrated 
in the blood and rose spots in a majority of the cases. They occur in the 
urine in 25 to 30 per cent of the cases. Their presence in sweat and 
sputa has been reported in a few instances. From the endocardial vegeta- 
tions, from meningeal and pleural exudates, and from foci of suppuration 
in various parts, the bacilli have also been isolated. 

(c) The Bacilli Outside the Body. — In sterile water the bacilli retain 
their vitality for weeks, but under ordinary conditions, in competition with 
saprophytes, disappear within fourteen days. Whether an increase in water 
can occur is not finally settled, but it probably may take place to some 
extent at first. Their detection in the water is difficult, and although 
they undoubtedly have been found, many such discoveries previously re- 
ported are not certain on account of the inaccurate differentiation of the 



TYPHOID FEVER. 



5 



typhoid bacillus and varieties of the colon bacillus closely resembling it. 
Both Prudden and Ernst have found it in water filters. 

In ice they may live as long as eighteen weeks, though a majority die 
within two weeks. 

In milk the bacilli undergo rapid development without changing its 
appearance. They may persist for three months in sour milk, and may 
live for several days in butter made from infected cream. 

Eobertson has shown that under entirely natural conditions typhoid 
bacilli may live in the upper layers of the soil for eleven months. In 
fasces, under ordinary conditions, they may live for months. 

The direct infection by dust of exposed food-stuffs, such as milk, is 
very probable. The bacilli retain their vitality for many weeks; in gar- 
den earth twenty-one days, in filter-sand eighty-two days, in dust of the 
street thirty days, on linen sixty to seventy days, on wood thirty-two days. 
(For additional details on the bacillus see Horton-Smith's Goulstonian 
Lectures, 1900.) 

Modes of Conveyance. — (a) Contagion. — The possibility of the direct 
transmission through the air from one person to another must be acknowl- 
edged, although, as shown by Germano, when completely dried in air-cur- 
rents, the specific bacillus quickly dies. There are house epidemics in 
which contamination of water or food could be almost positively excluded. 
The nurses and attendants who have to do with the stools and body-linen 
of the patients are alone liable to direct infection. During twelve years 
twenty physicians, nurses, or patients contracted the disease in my wards.* 
The contagion may be spread by means of clothing and wash-linen — a mode 
of infection which is especially to be feared in military garrisons, where 
the same clothing is sometimes used by different persons. 

(b) Infection of water is unquestionably the most common mode of 
conveyance. Many epidemics have been shown to originate in the con- 
tamination of a well or a spring. A very striking one occurred at Plym- 
outh, Pa., in 1885, which was investigated by Shakespeare. The town, 
with a population of 8,000, was in part supplied with drinking-water from 
a reservoir fed by a mountain stream. During January, February, and 
March, in a cottage by the side of and at a distance of from 60 to 80 feet 
from this stream, a man was ill with typhoid fever. The attendants were 
in the habit at night of throwing out the evacuations on the ground toward 
the stream. During these months the ground was frozen and covered with 
snow. In the latter part of March and early in April there was considerable 
rainfall and a thaw, in which a large part of the three months' accumulation 



* T)r. Futcher has kindly analyzed for me the cases of typhoid fever which have been 
contracted in the Johns Hopkins TTospital during the first twelve years of its work, to 
May, 1901. There have been 20 cases— 3 among 125 house officers, 2.4 per cent : 8 among 
291 nurses, 2.7 per cent. Seven patients contracted the disease while under treatment for 
other diseases among a total of 34,500. Four of these cases occurred in a small ward 
epidemic. One orderly contracted the disease while caring for typhoid patients, and one 
woman in charge of the linen room, where she handled clean linen only. There were 
2 cases of typhoid fever contracted by physicians working in the pathological laboratory. 



6 



SPECIFIC INFECTIOUS DISEASES. 



of discharges was washed into the brook, not 60 feet distant. At the very 
time of this thaw the patient had numerous and copious discharges. About 
the 10th of April cases of typhoid fever broke out in the town, appearing 
for a time at the rate of fifty a day. In all about 1,200 people were 
attacked. An immense majority of all the cases were in the part of the 
town which received water from the infected reservoir. 

The experience at Maidstone in 1897 illustrates the widespread and seri- 
ous character of an epidemic when the water-supply becomes badly con- 
taminated. The outbreak began about the middle of September, and 
within the first two weeks 509 cases were reported. By October 27th there 
were 1,748 cases, and by November 17th 1,848 cases. In all, in a popula- 
tion of 35,000, about 1,900 persons were attacked. Xo epidemic of the 
same magnitude has ever occurred in England, and it shows the terrible 
danger of a badly constructed water-supply easily contaminated by surface 
drainage. 

(c) Infection of Food.^— Milk may be the source of infection. One of 
the most thoroughly studied epidemics due to this cause was that investi- 
gated by Ballard in Islington. The milk may be contaminated by infected 
water used in cleaning the cans. The milk epidemics have been collected 
by Ernest Hart and by Kober, of Washington. 

The germs may be conveyed in ice, salads of various sorts, etc. The 
danger of eating celery and other uncooked vegetables, which have grown 
in soil on which infected material has been used as a fertilizer, must not 
be forgotten. 

Elies play an important part in the spread of the disease. Both in 
the Spanish-American and in the South African wars there was a perfect 
plague of flies, particularly in the enteric-fever tents, where they swarmed 
over everything. Food left uncovered for a few moments would be black 
with them. 

Oysters may become infected during the process of fattening or fresh- 
ening. In the Middletown epidemic, reported by H. W. Conn, the chain 
of circumstantial evidence seems complete; Lavis reports an epidemic oc- 
curring in Naples caused by infected oysters; and most suggestive sporadic 
cases have been recorded by Sir William Broadbent and others. 

C. J. Foote has made an interesting bacteriological study of the subject. 
Oysters taken from the feeding-grounds in rivers contain a very much 
larger number of micro-organisms of all sorts than those from the sea. He 
has shown, too, that Eberth's bacillus will live in the brackish water in 
which oysters are fattened even when frozen; and that it will also live in 
the oyster itself, and for a longer time than in the water in which the 
oyster grows. Whether multiplication takes place in the oyster is doubt- 
ful. Chantemesse also found typhoid germs in oysters which had lain in 
infected sea-water even after they had been transferred to and kept in 
fresh water for a time. 

(d) Contamination of the Soil — Pettenkofer holds that the poison is 
not eliminated in a condition capable of communicating the disease- di- 
rectly, but that it must first undergo changes in the soil, which changes 
are favored by the ground-water. 



TYPHOID FEVER. 



Filth, bad sewers, or cesspools can not in themselves cause typhoid 
fever, but they furnish the conditions suitable for the preservation of the 
bacillus, and possibly for its propagation. 

The history of typhoid fever in Munich, as told anew by Childs (Lan- 
cet, 1898, ii), indicates that the soil pollution has much to do with the oc- 
currence of sporadic cases and of recurrent outbreaks. However, it has 
been shown that in the deeper layers of the soil, where it would be influ- 
enced by the ground-water, the bacillus can not exist, much less multiply. 

Modes of Infection. — While the bacillus has its primary seat of action 
in the lymphatic tissues of the intestines, the fever is very largely due 
to its growth in the internal organs. As Maclagan very well puts it, the 
action is dual, one a local specific action of the parasite on the glands of 
the intestines, and a general action of the organism on the blood and 
tissues. A single bacillus in ten days, as he says, might produce a billion, 
and the incubation represents the period during which the bacilli are 
being reproduced. 

We may recognize the following groups: 1. Ordinary typhoid fever ivith 
marked enteric lesions. An immense majority of all the cases are of this 
character; and while the spleen and mesenteric glands are involved the 
lymphatic apparatus of the intestinal walls bears the brunt of the attack. 
2. Cases in which the intestinal lesions are very slight. The intestinal lesions 
may be found only after a very careful search. In reviewing the cases 
of " typhoid fever without intestinal lesions," Opie and Bassett call atten- 
tion to the fact that in many cases reported as without lesions slight lesions 
really did exist, while in others death occurred so late that slight lesions 
might have healed. In some of the cases the course of the disease is that 
of a general septicaemia with symptoms of severe intoxication and high 
fever and delirium. In others the main lesions may be in one or more of 
the different organs. The parts attacked may be the liver, gall-bladder, 
pleura, meninges, or even the endocardium. 3. Cases in which the typhoid 
bacillus enters the body without causing any lesion of the intestine. In a num- 
ber of the earlier cases reported as such the demonstration of the typhoid 
bacillus was inconclusive. In others the intestine showed tuberculous 
ulcers, through which the organisms may have entered. But after exclud- 
ing all these, a few cases remain in which the demonstration of the typhoid 
bacillus was conclusive, cases in which death occurred early, and yet after 
a very careful search no intestinal lesions could be found (Pick, Cheadle, 
Lartigau, Du Cazal). Undoubtedly the intestinal lesions may be so slight 
as not to be recognizable at autopsy. However, the number of such cases 
is too small to justify the assertion that typhoid bacilli can enter through 
an absolutely intact intestinal wall, though this possibility must be borne 
in mind. There is no conclusive evidence that typhoid bacilli can ever 
enter the body except through the intestinal tract. 4. Mixed infections. 
It is well to distinguish, as Dreschfeld points out, between double infec- 
tions, as with bacillus tuberculosis, the diphtheria bacillus, and the Plas- 
modia of Laveran, in which two different diseases are present and can be 
readily distinguished, and the true mixed or secondary infections, in which 
the conditions induced by one organism favor the growth of other pat he- 



8 



SPECIFIC INFECTIOUS DISEASES. 



genie forms; thus in the ordinary typhoid fever eases secondary infection 
with the colon bacillus, the streptococcus, staphylococcus, or the pneumococ- 
cus, is quite common. 5. Fevers due to organisms closely related to oacillus 
typhosus. During the past few years organisms very closely related to the 
typhoid bacillus, but differing in some cultural and agglutinating proper- 
ties, have been isolated by several observers (Widal, Gwyn, Gushing, Shott- 
muller) from cases clinically like typhoid. Whether these organisms have 
borne any etiological relationship to the cases in which they were found, 
or were only secondary invaders in cases of typhoid fever, is not yet certain. 

Products of the Growth of the Bacilli. — Brieger isolated from cultures 
a poison belonging to the group of ptomaines — typhotoxin. Later he and 
Fraenkel isolated a poison belonging to the group of toxalbumins. Ac- 
cording to Pfeiffer, the chief poison belongs to the intracellular group of 
toxins. Sidney Martin has isolated a poison which is in the nature of a 
secretion, but does not differ from that contained within the bacterial cell. 
Injected into animals it causes lowering of temperature, diarrhoea, loss 
of weight, and degeneration of the myocardium. Its chemical nature is 
not known. Similar, but weaker, poisons may also be isolated from cul- 
tures of bacillus coli communis and other members of this group. No 
toxins have yet been isolated which cause changes in animals at all com- 
parable to typhoid fever in human beings. 

Morbid Anatomy. — The statistical details under this heading are 
based upon eighty autopsies, a majority of which were performed at the 
Montreal General Hospital, and upon the records of two thousand post- 
mortems at the Munich Pathological Institute.* 

Intestines. — A catarrhal condition exists throughout the small and 
large bowel, and to this is due, in all probability, the diarrhoea with the 
thin pea-soup-like stools. Associated with this catarrh there is some epi- 
thelial desquamation. 

Specific changes occur in the lymphoid elements of the bowel, chiefly 
at the lower end of the ileum. The alterations which occur are most con- 
veniently described in four stages: 

1. Hyperplasia, which involves the glands of Peyer in the jejunum and 
ileum, and to a variable extent those in the large intestine. The follicles 
are swollen, grayish-white in color, and the patches may project to a dis- 
tance of from three to five mm. In exceptional cases they may be still 
more prominent. The solitary glands, which range in size from a pin's 
head to a large pea, are usually deeply imbedded in the submucosa, but 
project to a variable extent. Occasionally they are very prominent, and 
may be almost pedunculated. Microscopical examination shows at the 
outset a condition of hypersemia of the follicles. Later there is a great 
increase and accumulation of cells of the lymph-tissue which may even 
infiltrate the adjacent mucosa and the muscularis; and the blood-vessels 
are more or less compressed, which gives the whitish, anaemic appearance 
to the follicles. The cells have all the characters of ordinary lymph-cor- 
puscles. Some of them, however, are larger, epithelioid, and contain several 



* Miinchener meclicinische Wochenschrift, Nos. 3 and 4, 1891. 



TYPHOID FEVER. 



nuclei. Occasionally cells containing red blood-corpuscles are seen. This 
so-called medullary infiltration, which is always more intense toward the 
lower end of the ileum, reaches its height from the eighth to the tenth 
day and then undergoes one or two changes, resolution or necrosis. Death 
very rarely takes place at this stage. Resolution is accomplished by a fatty 
and granular change in the ceMs, which are destroyed and absorbed. A 
curious condition of the patches is produced at this stage, in which they 
have a reticulated appearance, the plaques a surface reliculee. The swoll- 
en follicles in the patch undergo resolution and shrink more rapidly than 
the surrounding framework, or what is more probable the follicles alone, 
owing to the intense hyperplasia, become necrotic and disintegrate, leaving 
the little pits. In this process superficial haemorrhages may result, and 
small ulcers may originate by the fusion of these superficial losses of sub- 
stance. 

There is nothing distinctive in the hyperplasia of the lymph-follicles 
in typhoid fever; but apart from this disease we rarely see in adults a 
marked affection of these glands with fever. In children, however, it is 
not uncommon when death has occurred from intestinal affections, and it 
is also met with in measles, diphtheria, and scarlet fever. 

2. Necrosis and Sloughing. — When the hyperplasia of the lymph-fol- 
licles reaches a certain grade, resolution is no longer possible. The blood- 
vessels become choked, there is a condition of anaemic necrosis, and 
sloughs form which must be separated and thrown off. The necrosis is 
probably due in great part to the direct action of the bacilli. The process 
may be superficial, affecting only the upper part of the mucous coat, or it 
may extend to and involve the submucosa. The " slough " may sometimes 
lie upon the Peyer's patch, scarcely involving the epithelium (Marchand). 
It is always more intense toward the ileo-caecal valve, and in very severe 
cases the greater part of the mucosa of the last foot of the ileum may be 
converted into a brownish-black eschar. The necrotic area in the solitary 
glands forms a yellowish cap which often involves only the most promi- 
nent point of a follicle. The extent of the necrosis is very variable. It 
may pass deep into the muscular coat, reaching to or even perforating the 
peritonaeum. 

3. Ulceration, — The separation of the necrotic tissue — the sloughing — 
is gradually effected from the edges inward, and results in the formation 
of an ulcer, the size and extent of which are directly proportionate to the 
amount of necrosis. If this be superficial, the entire thickness of the 
mucosa may not be involved and the loss of substance may be small and 
shallow. More commonly the slough in separating exposes the submucosa 
and muscularis, particularly the latter, which forms the floor of a majority 
of all typhoid ulcers. It is not common for an entire Peyer's patch to 
slough away, and a perfectly ovoid ulcer opposite to the mesentery is 
rarely seen. Irregularly oval and rounded forms are most common. A 
large patch may present three or four ulcers divided by septa of mucous 
membrane. The terminal 6 or 8 inches of the mucous membrane of the 
ileum may form a large ulcer, in which are here and there islands of 
mucosa. The edges of the ulcer are usually swollen, soft, sometimes con- 



10 



SPECIFIC INFECTIOUS DISEASES. 



gested, and often undermined. At a late period the ulcers near the valve 
may have very irregular sinuous borders. The base of a typhoid ulcer 
is smooth and clean, being usually formed of the submucosa or of the 
muscularis. 

There may be large ulcers near the valve and swollen rryperaemic patches 
of Peyer in the upper part of the ileum. 

4. Healing. — This begins with the development of a thin granulation 
tissue which covers the base and gives to it a soft, shining appearance. 
The mucosa gradually extends from the edge, and a new growth of epi- 
thelium is formed. The glandular elements are reformed; the healed 
ulcer is somewhat depressed and is usually pigmented. Occasionally an 
appearance is seen as if an ulcer had healed in one place and was extend- 
ing in another. In death during relapse healing ulcers may be seen in 
some patches with fresh ulcers in others. 

We may say, indeed, that healing begins with the separation of the 
sloughs, as, when resolution is impossible, the removal of the necrosed 
part is the first step in the process of repair. Practically, in fatal cases, 
we seldom meet with evidences of cicatrization, as the majority of deaths 
occur before this stage is reached. 

Large Intestine. — The caecum and colon are affected in about 4 one third 
of the cases. Sometimes the solitary glands are greatly enlarged. The 
ulcers are usually larger in the caecum than in the colon. 

Perforation of the Bowel. — Incidence at Autopsy. — In 114 cases of the 
2,000 Munich autopsies (5.7 per cent) and in 23 instances of my series, at 
the Johns Hopkins Hospital the intestine was perforated. According to 
Chomel, " the accident is sometimes the result of ulceration, sometimes of 
a true eschar, and sometimes it is produced by the distention of the intes- 
tine causing the rupture of tissues weakened by disease." In only a few 
cases is the perforation at the bottom of a clean thin-walled ulcer. In 
one instance it had occurred two weeks after the temperature had become 
normal. The sloughs are, as a rule, adherent about the site of perforation, 
which in a majority of the cases occur in small deep ulcers. There may be 
two or three perforations; in a few instances they have been very numer- 
ous. The orifice is usually within the last foot of the ileum. In only one 
of my cases was it distant 18 inches. In 4 cases of my series the appendix 
was perforated and in 2 the large bowel. Peritonitis was present in every 
instance. In 167 cases collected by Fitz the ileum was perforated in 136, 
the large intestine in 20, the appendix in 5, Meckel's diverticulum in 4, 
and the jejunum in 2. In the large intestine, according to Hawkins, the 
sigmoid flexure is the most frequent seat of perforation. 

Death from haemorrhage occurred in 99 of the Munich cases, and in 7 
of 63 deaths in my 829 cases. The bleeding seems to result directly 
from the separation of the sloughs. I was not able in any instance to find 
the bleeding vessel. In one case only a single patch had sloughed, and a 
firm clot was adherent to it. The bleeding may also come from the soft 
swollen edges of the patch. 

The mesenteric glands at first show intense hyperemia and subsequently 
become greatly swollen. Spots of necrosis are common. In several of my 



TYPHOID FEVER. 



11 



- cases suppuration had occurred, and in one a large abscess of the mesentery 
was present. Fatal haemorrhage into the peritonaeum may come from rup- 
ture of a swollen gland. The bunch of glands in the mesentery, at the 
lower end of the ileum, is especially involved. The retroperitoneal glands 
are also swollen. 

The spleen is invariably enlarged in the early stages of the disease. In 
only one of my cases did it exceed 20 ounces (600 grammes) in weight. 
The tissue is soft, even diffluent. Infarction is not infrequent. Eupture 
may occur spontaneously or as a result of injury. In the Munich autopsies 
there were 5 instances of rupture of the spleen, one of which resulted 
from a gangrenous abscess. 

The liver shows signs of parenchymatous degeneration. Early in the 
disease it is hyperaemic, and in a majority of instances it is swollen, some- 
what pale, on section turbid, and microscopically the cells are very granu- 
lar and loaded with fat. Nodular areas (microscopic) occur in many cases, 
as described by Handford. Eeed, in Welch's laboratory, could not deter- 
mine any relation between the groups of bacilli and these areas (Studies 
II). Some of the nodules are lymphoid, others are necrotic (Amyot). In 
12 of the Munich autopsies liver abscess was found, and in 3, acute yellow 
atrophy. Pylephlebitis may follow abscess of the mesentery or perforation 
of the appendix. Affections of the gall-bladder are not uncommon, and 
are fully described under the clinical features. 

Kidneys. — Cloudy swelling, with granular degeneration of the cells of 
the convoluted tubules, less commonly an acute nephritis, may be present. 
Kayer, Wagner, and others described the occurrence of numerous small 
areas infiltrated with round cells, which may have the appearance of 
lymphomata, or may pass on to softening and suppuration, producing the 
so-called miliary abscesses. It is usually a late change. The typhoid bacilli 
have been found in these areas. They may also be found in the urine. 
The kidneys in cases of typhoid bacilluria may show no changes other 
than cloudy swelling. Diphtheritic inflammation of the pelvis of the kid- 
ney may occur. It was present in 3 of my cases, in one of which the tips 
of the papillae were also affected. Catarrh of the bladder is not uncom- 
mon. Diphtheritic inflammation of this viscus may also occur. Orchitis 
is occasionally met with. 

Respiratory Organs. — Ulceration of the larynx occurs in a certain num- 
ber of cases; in the Munich series it was noted 107 times. It may come 
on at the same time as the ulceration in the ileum, but the bacilli have 
not yet, I believe, been found in the ulcers. They occur in the posterior 
wall, at the insertion of the cords, at the base of the epiglottis, and on the 
ary-epiglottidean folds. The cartilages are very apt to become involved. 
In the later periods catarrhal and diphtheritic ulcers may bo present. 

(Edema of the glottis was present in 20 of the Munich cases, in S of 
which tracheotomy was performed. Diphtheritis of the pharynx and larynx 
is not very uncommon. It occurred in a most extensive form in 2 of my 
cases. Lobar pneumonia may be found early in the disease (see PNETTMO- 
TYPHTJS), or it may be a late event. Hypostatic congestion and the con- 
dition of the lung spoken of as splenization are very common. Gangrene 



12 



SPECIFIC INFECTIOUS DISEASES. 



of the lung occurred in 40 cases in the Munich series; abscess of the lung 
in 14; hemorrhagic infarction in 129. Pleurisy is not a very common 
event. Fibrinous pleurisy occurred in about 6 per cent of the Munich 
cases, and empyema in nearly 2 per cent. 

Changes in the Circulatory System. — Heart Lesions. — Endocarditis is 
rare. I have met with 2 cases. The typhoid bacilli have been found in 
the vegetations. Pericarditis was present in 14 cases of the Munich au- 
topsies. Myocarditis is not very infrequent. Dewevre, in a series of 48 
cases, found in 16 granular or fatty degeneration, and in 3 a proliferating 
endarteritis in the small vessels. It is remarkable that even in cases of 
death from heart-failure, with intense fever, the cell-fibres may present 
little or no observable change. 

Lesions of the Blood-vessels — Typhoid Gangrene. — Inflammation of the 
arteries with thrombus formation has been frequently described in typhoid 
fever. Bacilli have been found in the thrombi. The artery may be 
blocked by a thrombus of cardiac origin — an embolus — but in the great 
majority of instances they are autochthonous and due to arteritis, oblit- 
erating or partial. Thrombosis in the veins is very much more frequent 
than in the arteries, but is not such a serious event. It is most frequent 
in the femoral, and in the left more often than the right. The conse- 
quences are fully considered under the symptoms. 

Nervous System. — There are very few obvious changes met with. Men- 
ingitis is extremely rare. No case occurred in our series. It occurred 
in only 11 of the 2,000 Munich cases. The exudation may be either serous, 
sero-fibrinous, or purulent, and typhoid bacilli have been frequently iso- 
lated. Two interesting cases have been reported by Ohlmaeher from the 
Cleveland City Hospital. In both bacilli were found in the meninges. In 
some of the cases, as Kamen^s, the enteric lesions have been slight. Optic 
neuritis, which occurs sometimes in typhoid fever, has not, so far as I know, 
been described in connection with the meningitis. The anatomical lesion 
of the aphasia — seen not infrequently in children — is not known, possibly 
it is an encephalitis. Parenchymatous changes have been met with in the 
peripheral nerves, and appear to be not very uncommon, even when there 
have been no symptoms of neuritis. 

The voluntary muscles show, in certain instances, the changes described 
by Zenker, which occur, however, in all long-standing febrile affections, 
and are not peculiar to typhoid fever. The muscle substance within the 
sarcolemma undergoes either a granular degeneration or a hyaline trans- 
formation. The abdominal muscles, the adductors of the thighs, and the 
pectorals are most commonly involved. Eupture of a rectus abdominis 
has been found post mortem. Hasmorrhage may occur. Abscesses may. 
develop in the muscles during convalescence. 

Symptoms. — In a disease so complex as typhoid fever it will be well 
first to give a general description, and then to study more fully the symp- 
toms, complications, and sequelae according to the individual organs. 

General Description.— The period of incubation lasts from "eight to 
fourteen days, sometimes twenty-three" (Clinical Society), during which 
there are feelings of lassitude and inaptitude for work. The onset is rarely 



TYPHOID FEVER. 



13 



abrupt. In the 829 cases there occurred at onset chills in 200, headache in 
595, anorexia in 414, diarrhoea (without purgation) in 322, epistaxis in 
182, abdominal pain in 227, constipation in 152, pain in right iliac fossa 
in 6. The patient at last takes to his bed, from which event, in a majority 
of cases, the definite onset of the disease may be dated. During the first 
week there is, in some cases (but by no means in all, as has long been 
taught), a steady rise in the fever, the evening record rising a degree or a 
degree and a half higher each day, reaching 103° or 104°. The pulse is rapid, 
from 100 to 110, full in volume, but of low tension and often dicrotic; the 
tongue is coated and white; the abdomen is slightly distended and tender. 
Unless the fever is high there is no delirium, but the patient complains of 
headache, and there may be mental confusion and wandering at night. 
The bowels may be constipated, or there may be two or three loose move- 
ments daily. Toward the end of the week the spleen becomes enlarged 
and the rash appears in the form of rose-colored spots, seen first on the 
skin of the abdomen. Cough and bronchitic symptoms are not uncommon 
at the outset. 

In the second week, in cases of moderate severity, the symptoms be- 
come aggravated; the fever remains high and the morning remission is 
slight. The pulse is rapid and loses its dicrotic character. There is no 
longer headache, but there are mental torpor and dulness. The face looks 
heavy; the lips are dry; the tongue, in severe cases, becomes dry also. 
The abdominal symptoms, if present — diarrhoea, tympanites, and tender- 
ness — become aggravated. Death may occur during this week, with pro- 
nounced nervous symptoms, or, toward the end of it, from haemorrhage or 
perforation. In mild cases the temperature declines, and by the four- 
teenth day may be normal. 

In the third week, in cases of moderate severity, the pulse ranges from 
110 to 130; the temperature now shows marked morning remissions, and 
there is a gradual decline in the fever. The loss of flesh is now more 
noticeable, and the weakness is pronounced. Diarrhoea and meteorism 
may now occur for the first time. Unfavorable symptoms at this stage are 
the pulmonary complications, increasing feebleness of the heart, and pro- 
nounced delirium with muscular tremor. Special dangers are perforation 
and haemorrhage. 

With the fourth week, in a majority of instances, convalescence begins. 
The temperature gradually reaches the normal point, the diarrhoea stops, 
the tongue cleans, and the desire for food returns. In severe cases the 
fourth and even the fifth week may present an aggravated picture of the 
third; the patient grows weaker, the pulse is more rapid and feeble, the 
tongue dry, and the abdomen distended. He lies in a condition of pro- 
found stupor, with low muttering delirium and subsultus tendinum, and 
passes the faeces and urine involuntarily. Heart-failure and secondary 
complications are the chief dangers of this period. 

In the fifth and sixth weeks protracted cases may still show irregular 
fever, and convalescence may not set in until after the fortieth day. In this 
period we meet with relapses in the milder forms or slighl recrudescence of 
the fever. At this time, too, occur many of the complications and sequelae. 



SPECIFIC INFECTIOUS DISEASES, 



Special Features and Symptoms. — Mode of Onset. — As a rule, the 
symptoms come on insidiously, and the patient is unable to fix definitely 
the time at which he began to feel ill. The following are the most impor- 
tant deviations from this common course: 

(a) Onset with Pronounced, sometimes Sudden, Nervous Manifestations. 
— Headache, of a severe and intractable nature, is by no means an infre- 
quent initial symptom. Again, a severe facial neuralgia may for a few 
days put the practitioner off his guard. In cases in which the patients 
have kept about and, as they say, fought the disease, the very first mani- 
festation may be pronounced delirium. Such patients may even leave 
home and wander about for days. In rare cases the disease sets in with 
the most intense cerebro-spinal symptoms, simulating meningitis — severe 
headache, photophobia, retraction of the head, twitching of the muscles, 
and even convulsions. Occasionally drowsiness, stupor, and signs of basi- 
lar meningitis may exist for ten days or more before the characteristic 
symptoms develop; the onset may be with mania. 

(b) With Pronounced Pulmonary Symptoms. — The initial bronchial 
catarrh may be of great severity and obscure the other features of the 
disease. More striking still are those cases in which the disease sets in 
with a single chill, with pain in the side and all the characteristic features 
of lobar pneumonia, or of acute pleurisy; or tuberculosis is suspected. 

(c) With Intense G 'astro-intestinal Symptoms. — The incessant vomiting 
and pain may lead to a suspicion of poisoning, or the case may be sent to 
the surgical wards for appendicitis. 

(d) With symptoms of an acute nephritis, smoky or bloody urine, with 
much albumin and tube-casts. 

(e) Ambulatory Form. — Deserving of especial mention are those cases 
of typhoid fever in which the patient keeps about and attempts to do 
work, or perhaps takes a long journey to his home. He may come under 
observation for the first time with a temperature of 104° or 105°, and with 
the rash well out. Many of these cases run a severe course, and in general 
hospitals they contribute largely to the total mortality. Finally, there 
are rare instances in which typhoid is unsuspected until perforation, or a 
profuse haemorrhage from the bowels occurs. 

Facial Aspect. — Early in the disease the cheeks are flushed and the 
eyes bright. Toward the end of the first week the expression becomes 
more listless, and when the disease is well established the patient has a 
dull and heavy look. There is never the rapid anaemia of malarial fever, 
and the color of the lips and cheeks may be retained even to the third week. 

Fever. — (a) Regular Course. (Chart I.) — In the stage of invasion the 
fever rises steadily during the first five or six days. The evening tem- 
perature is about a degree or a degree and a half higher than the morn- 
ing remission, so that a temperature of 104° or 105° is not uncommon 
by the end of the first week. Having reached the fastigium or height, 
the fever then persists with very slight daily remissions. The fever may 
be singularly persistent and but little influenced by bathing or other 
measures. At the end of the second and throughout the third week the 
temperature becomes more distinctly remittent. The difference between 



TYPHOID FEVER. 



15 



, «? i-f its © "5 cs ■« es ©; «q © 




16 



SPECIFIC INFECTIOUS DISEASES. 



the morning and evening record may be 3° or 4°, and the morning tempera- 
ture may even be normal. It falls by lysis, and the temperature is not 
considered normal until the evening record is at 98.2°. 

(b) Variations from the typical temperature curve are common. We 
do not always see the gradual step-like ascent in the early stage; the cases 
do not often come under observation at this time. When the disease sets 
in with a chill, or in children with a convulsion, the temperature may rise 
at once to 103° or 104°. In many cases defervescence occurs at the end of 
the second week and the temperature may fall rapidly, reaching the nor- 
mal within twelve or twenty hours. An inverse type of temperature, high 
in the morning and low in the evening, is occasionally seen but has no 
especial significance. 

Sudden falls in the temperature may occur; thus, as shown in Chart 
III, a drop of 10° may follow an intestinal haemorrhage, and the fall may 
be very apparent even before the blood has appeared in the stools. Some- 
times during the anaemia which follows a severe haemorrhage from the 
bowels there are remarkable oscillations in the temperature. Hyperpy- 
rexia is rare. In only 33 of 829 cases did the fever rise above 106°. Before 
death the fever may rise; the highest I have known was 109.5°. 

(c) Post-typhoid Variations. (1) Recrudescences. — After a normal tem- 
perature of perhaps five or six days, the fever may rise suddenly to 102° or 
103°, without constitutional disturbance, furring of the tongue, or abdomi- 
nal symptoms. After persisting for from two to four days the tempera- 
ture falls. Of 829 cases, 79 presented these post-typhoid elevations, brief 
notes of which are given in the Studies on Typhoid Fever. Constipation, * 
errors in diet, or excitement may cause them. These attacks are a frequent 
source of anxiety to the practitioner. They are very common, and it is 
not always possible to say upon what they depend. As a rule, if the rise 
in temperature is the result of the onset of a complication, such as pleurisy 
or thrombosis, there is an increase in the leucocytes. Naturally one sus- 
pects at the outset a relapse, but there is an absence of the step-like ascent, 
and as a rule the fever falls after lasting a few days. 

(2) The Sub-febrile State of Convalescence. — In children, in very nerv- 
ous patients, and in cases with anaemia, the evening temperature may keep 
up for weeks after the tongue has cleaned and the appetite has returned. 
This may usually be disregarded, and is often best treated by allowing the 
patient to get up, and by stopping the use of the thermometer. Of course 
it is important not to overlook any latent complications. 

(3) Hypothermia. — Low temperatures in typhoid fever are common, 
following the tubs, or spontaneously in the third and fourth week in the 
periods of marked" remissions, and following haemorrhage. An interesting- 
form is the persistent hypothermia of convalescence. For ten days or more, 
particularly in the protracted cases with great emaciation, the tempera- 
ture may be 96.5° or 97°. It is of no special significance. 

(d) The Fever of the Relapse. — This is a repetition in many instances 
of the original fever, a gradual ascent and maintenance for a few days at 
a certain height and then a gradual decline. It is shorter than the original 
pyrexia, and rarely continues more than two or three weeks. (Chart I.) 



TYPHOID FEVER. 



17 



(e) Afebrile Typhoid. — There are eases described in which the chief 
features of the disease have been present without the existence of fever. 
They are extremely rare in this country. I have seen a case, afebrile at the 
thirteenth day, and in which the rose spots and other features persisted 
till the twenty-eighth day. 

(f) Chills occur (a) sometimes with the fever of onset; (b) occasion- 
ally at intervals throughout the course of the disease, and followed by 
sweats (so-called sudoral form); (c) with the advent of complications, 
pleurisy, pneumonia, otitis media, periostitis, etc.; (d) with active anti- 
pyretic treatment by the coal-tar remedies; (e) occasionally during the 
period of defervescence without relation to any complication or sequel, 
probably due to a septic infection; (/) according to Herringham, chills 
may result from constipation. There are cases in which throughout the 
latter half of the disease chills recur with great severity. (See Chills in 
Typhoid Fever, Studies II.) 

Skin. — The characteristic rash of the disease consists of hyperamric 
spots, which appear from the seventh to the tenth day, usually at first 
upon the abdomen. They are slightly raised, flattened papules, which can 
be felt distinctly by the finger, of a rose-red color, disappearing on pres- 
sure, and ranging in diameter from 2 to 4 mm. They were present in 666 
of our 829 cases. They come out in successive crops, and after persisting 
for two or three days they disappear, leaving a brownish stain. The spots 
may be present upon the back, and not upon the abdomen. The eruption 
may be very abundant over the whole skin of the trunk, and on the extremi- 
ties. Of 426 cases in which the spots were looked for with particular care, 
there were 39 in which they occurred on the arms, 13 on the forearms, 19 on 
the thighs, legs 8, face 3, hands 1. The cases with very abundant eruption 
are not necessarily more severe. As already noted, the typhoid bacilli 
have been found in the spots. Of variations in the rash, frequently the 
spots are capped by small vesicles. Cases that have not been carefully 
sponged may show sweat vesicles, either miliary or sudaminal. In 25 cases 
in my series there were purpuric spots. One of the cases was true hemor- 
rhagic typhoid fever. The rash may not appear until the relapse. In 12 
cases in our series the rose spots came out after the patient was afebrile. 

A branny desquamation is not rare in children. Occasionally the skin 
peels off in large flakes. 

Among other skin lesions in typhoid fever the following may be men- 
tioned: 

Erythema. — It is not very uncommon in the first week of the disease to 
And a diffuse erythematous blush — E. typhosus. Formerly we thought 
this might be due to quinine. 

The tache cerebrale, a red line with white borders, is readily produced 
by drawing the nail over the skin, a vaso-motor phenomenon of no special sig- 
nificance. Sometimes the skin may have a peculiar mottled pink and white 
appearance. E. exudativum, E. nodosum, and urticaria may be present. 

Herpes. — Herpes is certainly rare in typhoid fever in comparison with 
its great frequency in malarial fever and in pneumonia. It was noted in 
29 of our 829 cases, usually on the lips. 
2 



18 



SPECIFIC INFECTIOUS DISEASES. 



The taches bleuatres — Peliomata — Macula? cerulece. — These are pale-blue 
or steel-gray spots, subcuticular, from 4 to 10 mm. in diameter, of irregu- 
lar outline and most abundant about the chest, abdomen, and thighs. 
They sometimes give a very striking appearance to the skin. It can be 
readily seen that the injection is in the deeper tissues and not superficial. 
This rash is quite without significance. Since my attention was called to 
its association with body lice, I have met with no instance in which these 
were not present. Several French observers maintain that they are due to 
the irritating effects of the fluid secreted by pediculi (vide Hewetson, Johns 
Hopkins Hospital Bulletin, vol. v). They are not peculiar to typhoid fever 
(Duckworth). 

Skin Gangrene. — In children noma may occur; occasionally, as reported 
by McFarland in the Philadelphia epidemic of 1898, there were many 
cases with multiple areas of gangrene of the skin. 

Sweats. — At the height of the fever the skin is usually dry. Profuse 
sweating is rare, but it is not very uncommon to see the abdomen or chest 
moist with perspiration, particularly in the reaction which follows the 
bath. Sweats in some instances constitute a striking feature of the dis- 
ease. They may occasionally be associated with chilly sensations or actual 
chills. Jaccoud and others in France have especially described this sudoral 
form of typhoid fever. There may be recurring paroxysms of chill, fever, 
and sweats (even several in twenty-four hours), and the case may be mis- 
taken for one of intermittent fever. The fever toward the end of the 
second week and during the third week may be intermittent. The char- 
acteristic rash is usually present, and, if absent, the negative condition of 
the blood is sufficient to exclude malaria. The sweating may occur chiefly 
in the third and fourth weeks. 

(Edema of the skin occurs: 1. As the result of vascular obstruction, 
most commonly of a vein, as in thrombosis of the femoral vein. 

2. In connection with nephritis, very rarely. 

3. In association with the anosmia and cachexia. 

The hair falls out after the attack, but complete baldness is rare. I 
have once seen permanent baldness. The nutrition of the nails suffers, 
and during and after convalescence transverse ridges may occur. 

A peculiar odor is exhaled from the skin in some cases. Whether due 
to a cutaneous exhalation or not, there certainly is a very distinctive smell 
connected with many patients. Nathan Smith describes it as of a " semi- 
cadaverous, musty character." 

Linece atrophica?. — Lines of atrophy may appear on the skin of the abdo- 
men and lateral aspects of the thighs, similar to those seen after preg- 
nancy. They have been attributed to neuritis, and Duckworth has reported 
a case in which the skin adjacent to them was hyperassthetic. 

Bed-sores are not uncommon in protracted cases, with great emacia- 
tion. As a rule, they result from pressure and are seen upon the sacrum, 
more rarely the ilia, the shoulders, and the heels. These are less com- 
mon, I think, since the introduction of hydrotherapy. Scrupulous care 
and watchfulness do much for their prevention, but it is to be remem- 
bered that in cases with profound involvement of the nerve centres acute 



TYPHOID FEVER. 



19 



bed-sores of the back and heels may occur with very slight pressure, and 
with astonishing rapidity. 

Boils constitute a common and troublesome sequel of the disease. 
They appear to be more frequent after hydrotherapy. 

Circulatory System. — The blood presents important changes. The fol- 
lowing statements are based on studies which W. S. Thayer has made in 
my wards (Studies I and III): During the first two weeks there may be 
little or no change in the blood. Profuse sweats or copious diarrhoea may, 
as Hayem has shown, cause the corpuscles — as in the collapse stage of 
cholera — to rise above normal. In the third week a fall usually takes 
place in corpuscles and haemoglobin, and the number may sink rapidly 
even to 1,300,000 per c. mm., gradually rising to normal during conva- 
lescence. When the patient first gets up, there may be a slight fall in the 
number of corpuscles. The average maximum loss is about 1,000,000 to 
the c. mm. 

The amount of haemoglobin is always reduced, and usually in a greater 
relative proportion than the number of red corpuscles, and during recov- 
ery the normal color standard is reached at a later period. The number 
of colorless corpuscles is subnormal throughout the course. Cold baths 
increase temporarily the number in the peripheral circulation. The ab- 
sence of leucocytosis may be at times of real diagnostic value in distin- 
guishing typhoid fever from various septic fevers and acute inflammatory 
processes. The relative proportion of the leucocytes shows fairly constant 
variations, the large mononuclear and transitional forms are increased, 
while the polynuclear neutrophiles are diminished often below 60 or even 
50 per cent. This is in marked contrast to the condition in other acute 
diseases in which the polynuclear neutrophiles are increased. When an 
acute inflammatory process occurs in typhoid fever the leucocytes show 
an increase in the polynuclear forms, and this may be of great diagnostic 
moment, as in perforation. 

The accompanying blood-chart shows these changes well. (Chart II.) 

The post-typhoid anaemia may reach an extreme grade. In one of my 
cases the blood-corpuscles sank to 1,300,000 per c. mm. and the haemo- 
globin to about 20 per cent. These severe grades of anaemia are not com- 
mon in my experience. In the Munich statistics there were 54 cases with 
general and extreme anaemia. 

Of changes in the blood plasma very little is known. 

The pulse in typhoid fever presents no special characters. It is in- 
creased in rapidity, but not always in proportion to the height of the 
fever. As a rule, in the first week it is above 100, full in volume and often 
dicrotic. There is no acute disease with which, in the early stage, a 
dicrotic pulse is so frequently associated. Even with high fever the pulse 
may not be greatly accelerated. As the disease progresses the pulse be- 
comes more rapid, feebler, and small. In the extreme prostration of severe 
cases it may reach 150 or more, and is a mere undulation — the so-called 
running pulse. The lowered arterial pressure is manifest in the dusky 
lividity of the skin and coldness of the hands and feet. 

During convalescence the pulse gradually returns to normal, and occa- 



20 



SPECIFIC INFECTIOUS DISEASES. 



sionally becomes very slow. After no other acute fever do we so fre- 
quently meet with bradycardia. I have counted the pulse as low as 30, 
and instances are on record of still fewer beats to the minute. 



100% 


5,000,000 


DEC , 1 


890 




JANUARY, 


169.1 


FEBRUARY,. 


MARCH 


























24 








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1 9 




































































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20% 


1,000,000 


































































































































10% 


500,000 


































































































































































































— S 




10,000 


































































8,000 


































































6,000 
























































.... 










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BLACK, RED CORPUSCLES. RED, HAEMAGLOBIN. BLUE, COLORLESS CORPUSCLES. 

Chart II. 

The heart-sounds may be normal throughout the course. In severe 
cases, the first sound becomes feeble and there is often to be heard, at the 
apex and along the left sternal margin, a soft systolic murmur. Absence 
of the first sound is rare. Gallop rhythm is not uncommon. In the ex- 
treme feebleness of the graver forms, the first and second sound become very 
similar, and the long pause is much shortened (embryocardia). I am much 
impressed with the rarity of grave heart symptoms in typhoid fever. 

Of cardiac complications, pericarditis is rare and has been met with 
chiefly in children and in association with pneumonia. It was present in 



TYPHOID FEVER. 



21 



only one of my eases and occurred in only 14 of the 2,000 Munich post- 
mortems. Endocarditis is also uncommon. I have seen only 2 cases; and 
there were only 11 cases noted in the Munich records. Myocarditis is more 
common. The following statement may be made with reference to the 
condition of the heart-muscle in this disease: In protracted cases the mus- 
cle-fibre is usually soft, flabby, and of a pale yellowish-brown color. The 
softening may be extreme, though rarely of the grade described by Stokes, 
in which, when held apex up by the vessels, the organ collapsed over the 
hand, forming a mushroom-like cap. Microscopically, the fibres may show 
little or no change, even when the impulse of the heart has been extremely 
feeble. A granular parenchymatous degeneration is common. Fatty de- 
generation may be present, particularly in long-standing cases with anaemia. 
The hyaline change is not common. The segmenting myocarditis, in which 
the cement substance is softened so that the muscle-cells separate, has 
also been found, but probably as a post-mortem change. 

Complications in the Arteries. — Obliteration of large or small arterial 
trunks is one of the rare complications of typhoid fever. A considerable 
number of cases are scattered through the literature. The obliteration 
may be due either to embolism or to thrombosis. In a majority of cases 
the femoral artery is involved and gangrene of the foot and leg occurs. 
In several cases there has been obliteration of both femorals with extension 
of the clot into the aorta with gangrene of both legs. In a case which 
I saw with Eoddick, of Montreal, the obliteration of the left femoral 
occurred on the sixteenth day. On the twentieth day the patient had 
pain in the right leg and there was no pulsation in the femoral arttry. 
Gangrene gradually developed in both feet, and death took place in the 
sixth week. In these cases the condition is probably due to thrombosis, 
not embolism, and is associated with a blood state which favors clotting, 
or with a local arteritis, a view strongly supported by Auden in a recent 
study. Keen refers to 46 cases of arterial gangrene, of which 8 were bilat- 
eral, 19 on the right side, and 19 on the left. 

Thrombi in the Veins. — This not infrequent complication was present 
in 16 of 829 cases — 7 in left femoral, 4 in popliteal, 4 in the long 
saphenous, and 1 in a superficial vein. The more common occurrence in 
the left crural vein is due possibly, as suggested by Liebermcister, to the 
fact that in the left common iliac vein, being crossed by the right iliac 
artery, the flow of blood is not so free as in the right vein. Thrombosis 
is indicated by enlargement and oedema of the limb. It is not a very 
unfavorable complication. In a Montreal case the thrombus suppurated 
and there was pyaemia. Occasionally the thrombosis may extend into 
the pelvic veins and into the vena cava. I saw a thrombus in the right 
circumflex iliac vein alone, and the superficial veins on the right side 
of the abdomen were in consequence greatly enlarged. Sudden death has 
been caused by dislodgment of a thrombus and plugging of the pulmonary 
artery. Typhoid bacilli have been found in the wall of the vein and in 
the clot. Gangrene never follows clotting in the vein alone. The phleg- 
masia alba dolens which results gradually disappears as the collateral cir- 
culation is established. It may be weeks before the swelling subside s. 



22 



SPECIFIC INFECTIOUS DISEASES. 



Some patients have to wear a bandage for years, and in a few instances 
the leg remains permanently enlarged. The pain is variable. 

Infarcts in the kidneys, spleen, and lungs are by no means nncommon 
in typhoid fever. They are associated usually with thrombosis in the arte- 
ries, rarely with embolism. 

Typhoid Gangrene. — Following blocking of the femoral or popliteal 
arteries the leg becomes numb and cold. There may be complete anaes- 
thesia with motor paralysis, and occasionally a good deal of pain. There 
is rarely much swelling; gradually the skin becomes discolored and the 
process of dry gangrene begins. "When both artery and vein are involved 
the gangrene is usually moist, and spreads more rapidly. In a number of 
cases the gangrene is not specially localized to vascular areas; thus the dis- 
tribution in the cases collected by Keen is as follows: Ears, 6 cases; nose, 
10 cases; face, neck, and trunk, -17 cases; anus, 5 cases; genitals, 20 cases; 
legs, 126 cases. 

Digestive System. — Loss of appetite is early, and, as a rule, the relish 
for food is not regained until convalescence. Thirst is constant, and 
should be fully and freely gratified. Even when the mind becomes be- 
numbed and the patient no longer asks for water, it should be freely given. 
The tongue presents the changes inevitable in a prolonged fever, but there 
are no distinctive characters. Early in the disease it is moist, swollen, and 
coated with a thin white fur, which, as the fever progresses, becomes 
denser. It may remain moist throughout. In severe cases, particularly 
those with delirium, the tongue becomes very dry, partly owing to the fact 
that such patients breathe with the mouth open. It may be covered with 
a brown or brownish-black fur, or with crusts between which are cracks 
and fissures. Acute glossitis occurred in one case at the onset of the 
relapse. In these cases the teeth and lips may be covered with a dark 
brownish matter called sordes — a mixture of food, epithelial debris, and 
micro-organisms. By keeping the mouth and tongue clean from the out- 
set the fissures, which are extremely painful, may be prevented. During 
convalescence the tongue gradually becomes clean, and the fur is thrown 
off, almost imperceptibly or occasionally in flakes. 

The secretion of saliva is often diminished; salivation is rare. 

Parotitis was present in 45 of the 2,000 Munich cases. It occurred in 
12 cases in my series; of these, 4 died. It is most frequent in the third 
week in very severe cases. Extensive sloughing may follow in the tissues 
of the neck. Usually unilateral, and in a majority of cases going on to 
suppuration, it is regarded as a very fatal complication, but recovery has 
followed in eight of my cases. It undoubtedly may arise from extension 
of inflammation along Steno's duct. This is probably not so serious a 
form as when it arises from metastatic inflammation. In two of my cases 
the submaxillary glands were involved alone. Parotitis may occur after the 
fever has subsided. A remarkable localized sweating in the parotid region 
is an occasional sequel of the abscess. 

The pharynx may be the seat of slight catarrh. Sometimes the fauces 
are deeply congested. Membranous pharyngitis, a serious and fatal com- 
plication, may come on in the third week. Difficulty in swallowing may 



TYPHOID FEVER. 



23 



result from ulcers of the oesophagus, and in one of our cases stricture fol- 
lowed.* Thyroiditis ma}^ occur with abscess formation. 

The gastric symptoms are extremely variable. Nausea and vomiting 
are not common. There are instances, however, in which vomiting, re- 
sisting all measures, is a marked feature from the outset, and may directly 
cause death from exhaustion. Vomiting does not often occur in the second 
and third week, unless associated with some serious complication. In a 
few of these cases ulcers have been found in the stomach. Hasmatemesis 
may occur. 

Intestinal Symptoms. — Diarrhoea is a very variable symptom, occurring 
in from 20 to 30 per cent of the cases. Of 829 cases 322 had diarrhoea 
before entering, 163 during their stay in, hospital. The small percentage 
may be due to the fact that we use no purges or intestinal antiseptics. Its 
absence must not be taken as an indication that the intestinal lesions are 
of slight extent. I have seen, on several occasions, the most extensive infil- 
tration and ulceration of the Peyer's glands of the small intestine, with 
the colon filled with solid faeces. The diarrhoea is caused less by the ulcers 
than by the associated catarrh, and, as in tuberculosis, it is probable that 
when this is in the large intestine the discharges are more frequent. It is 
most common toward the end of the first and throughout the second week, 
but it may not occur until the third or even the fourth week. The number 
of discharges ranges from 3 to 8 or 10 in the twenty-four hours. They are 
usually abundant, thin, grayish-yellow/ granular, of the consistency and 
appearance of pea-soup, and resemble very much, as Addison remarked, the 
normal contents of the small bowel. The reaction is alkaline and the odor 
offensive. On standing, the discharges separate into a thin serous layer, 
containing albumin and salts, and a lower stratum, consisting of epithelial 
debris, remnants of food, and numerous crystals of triple phosphates. 
Blood may be in small amount, and only recognized by the microscope. 
Sloughs of the Peyer's glands occur either as grayish-yellow fragments or 
occasionally as ovoid masses, an inch or more in length, in which portions 
of the bowel tissue may be found. The bacilli are not found in the stools 
until the end of the first or the middle of the second week. 

Haemorrhage from the bowels is a serious complication, occurring in 
from 3 to 5 per cent of all cases. It had occurred in 99 of the 2,000 fatal 
Munich cases. In 829 cases treated in my wards, haemorrhage occurred 
in 50, and in 7 death occurred directly from the haemorrhage. Of 60 
cases reported by R. G. Curtin, 28 died. It was present in 3.77 per cent of 
Murchison's 1,564 cases. There may be only a slight trace of blood in the 
stools, but too often it is a profuse, free haemorrhage, which rapidly proves 
fatal. It occurs most commonly between the end of the second and the 
beginning of the fourth week, the time of the separation of the sloughs. 
Occasionally it results simply from the intense liyporannia. It usually 
comes on without warning. A sensation of sinking or collapse is experi- 
enced by the patient, the temperature Tails, and may, as in the annexed 
chart, drop 8° or 10° in a few hours. Fatal collapse may supervene before 



* Mitchell, (Esophageal Complications in Typhoid Fever (Studies III). 



24 



SPECIFIC INFECTIOUS DISEASES. 



the blood appears in the stool. Haemorrhage usually occurs in cases of 
considerable severity. Graves and Trousseau held that it was not a very 
dangerous symptom, but statistics show that death follows in from 30 to 
50 per cent of the cases. 




It must not be forgotten that melsena may also be part of a general 
hemorrhagic tendency (to be referred to later), in which case it is associ- 
ated with petechia? and hematuria. There may be a special family pre- 
disposition to intestinal haemorrhages in typhoid fever. 

Meteorism, a frequent s} T mptom, is not serious if of moderate grade, 
Irat when excessive is usually of ill omen. Owing to defective tone in the 



TYPHOID FEVER. 



2o 



walls, in . severe cases to their infiltration with serum, gas .accumulates in 
the small and large bowels, particularly in the latter. Pushing up the 
diaphragm, it interferes very much with the action of the heart and lungs, 
and may also favor perforation. Gurgling in the right iliac fossa exists 
in a large proportion of all the cases, and indicates simply the presence 
of gas and fluid faeces in the colon and caecum. 

Abdominal pain and tenderness were present in three-fifths of a series 
of 500 cases studied in my wards by T. McCrae. In some it was only pres- 
ent at the onset. Pain occurred during the course in about one-third of the 
cases. This is due in some instances to conditions apart from the bowel 
lesions, such as pleurisy, distention of the bladder, and phlebitis. It may 
be associated with diarrhoea, severe constipation, a painful spleen, or acute 
abdominal complications. Pain occurs with some cases of haemorrhage, 
but is most constantly present with perforation. In a large group no cause 
could be found for the pain, and if other symptoms be associated the con- 
dition may lead to error in diagnosis. Operation for appendicitis has been 
performed in the early stage of typhoid fever, owing to the combination 
of pain in the right iliac fossa, fever and constipation. This has happened 
twice at the Johns Hopkins Hospital. 

Perforation. — The patient's life may depend upon an early recognition 
of the condition. It occurred in 23 of 829 cases in our series, 2.7 per cent. 
Nearly one half of the cases occur in the third and fourth weeks (Fitz). 
It may occur as early as the first week, or as late as the sixteenth week. 
While it may occur in very mild cases, a large proportion occur in the 
more severe forms, particularly in those associated with meteorism and 
with haemorrhage. 

The symptoms are, first, those of the perforation itself; secondly, those 
of the consecutive peritonitis. By far the most important single symp- 
tom of the perforation is pain, sudden, sharp, paroxysmal, and of increasing- 
severity. It is rarely absent, except in the small group of cases with pro- 
found toxaemia and coma. The pain is most frequently in the hypogastric 
region, and to the right of the middle line. As it occurs in the lowermost 
coils of the ileum, irritability of the bladder may be early, with frequent 
micturition and pain extending toward the penis. On palpation there 
may be general tenderness in the hypogastric region, or only localized 
tenderness on deep pressure. There may be early muscle rigidity and in- 
creased tension, and spasm on any attempt to palpate. In a few instances, 
with the pain of perforation, the patient has signs of shock, fall in tem- 
perature, increase in the rapidity of the pulse, and a tendency to sweat. 
The physician should note in writing, at once, after the onset of pain, the 
condition of the abdomen, particularly the character of the respiratory 
movements, the degree of distention, and the area of liver flatness. A 
leucocyte count should be made. 

In a few instances, as in a remarkable rase recently reported by J. 
Milton Miller, the perforation is completely closed by a tag of omentum. 
The symptoms of typhoid peritonitis may be masked and entirely over- 
looked in a profound toxaemia. They are general and local. The facies 
of the patient usually changes, there are increased pallor, a pinched ex- 



26 SPECIFIC INFECTIOUS DISEASES. 

/ 

pression, and, as the symptoms progress, the Hippocratic facies, with dusky 
suffusion of the face and clammy perspiration. The temperature may 
drop at the onset of the perforation, but usually rises with the progress 
of the peritonitis. The pulse quickens, becoming finally running and 
thready, and there is embryocardia. Increase in the frequency of respira- 
tion is almost constant. Hiccough may occur early, more frequently a 
late symptom. Vomiting is a common symptom. 

The local abdominal features are often more important than the gen- 
eral, as it is surprising to notice how excellent the condition of a patient 
may be with perforative peritonitis. Limitation of the respiratory move- 
ments is usually present, perhaps confined to the hypogastric area. In- 
creasing distention is the rule, but perforation and peritonitis may occur, 
it is to be remembered, with an abdomen flat or even scaphoid. Increasing 
pain on pressure, increasing muscle spasm and tension of the wall are im- 
portant signs. Percussion may reveal a flat note in the flanks, due to 
exudate. Auscultation may show absence of peristalsis, and auscultatory 
percussion my possibly show the presence of air free in the peritonaeum. 
A friction may be present within twelve hours of the onset of the per- 
foration. Obliteration of the liver flatness in the nipple line may be 
caused by excessive tympany. Eapid obliteration of liver flatness in a flat, 
or a not much distended abdomen, is a valuable sign. Examination of the 
rectum may show fullness in the pelvis, or tenderness. 

In a majority of all cases there is a rise in the leucocytes, and when 
present may be a valuable help, but it is not constant. 

General peritonitis, without perforation of the bowel, may occur by 
extension from an ulcer, or by rupture of a softened mesenteric gland, 
or, as in one recent case in my series, from inflammation of the Fallopian 
tubes. It was present in 2.2 per cent of the Munich autopsies. 

The spleen is usually enlarged, and the edge was felt below the costal 
margin in 71 per cent of my cases. Percussion is uncertain, as, owing to 
distention of the stomach and colon, even the normal area of dullness may 
not be obtainable. I have seen a very large spleen post mortem, when 
during life the increase in size was not observable. 

Liver. — Symptoms on the part of this organ are rare. 

(a) Jaundice was present in only 3 cases of my series. Catarrh of 
the ducts, toxaemia, abscess, and occasionally gall-stones are the usual 
causes. 

(I) Abscess. — Solitary abscess is exceedingly rare and occurred in but 
2 cases in my series. It may follow the intestinal lesion or more commonly 
one of the complications, as parotitis or necrosis of bone. Suppurative 
pylephlebitis, which is more frequent than abscess, may follow perforation 
of the appendix. Suppurative cholangitis has been described. 

(c) Cholecystitis is a comparatively frequent complication. Camac * 
has collected 115 cases, in 21 of which perforation occurred. Pain in the 
region of the gall-bladder is the most constant symptom. Tenderness, 
muscle spasm, and the presence of a gall-bladder tumor are present in 



* Studies in Typhoid Fever, Series III, Johns Hopkins Hospital Reports, toI. viii. 



TYPHOID FEVER. 27 

a majority of the cases. Jaundice is inconstant. With perforation there 
may be a marked drop in the fever and the onset of signs of peritonitis. 
In simple cholecystitis the urgency of the symptoms may abate, and re- 
covery may follow. Suppuration may occur with infection of the bile pas- 
sages. Months or years after (eighteen years in Hunner's case) the bacilli 
may cause cholecystitis or gall-stones. Typhoid bacilli have been found by 
Gushing as a cause of cholecystitis in a patient who had never had typhoid 
fever. 

(d) Gall-Stones. — Bernheim called attention to the frequency of chole- 
lithiasis after typhoid fever. It is probably associated with the presence 
of typhoid bacilli in the gall-bladder (see under Gall-Stones). 

Respiratory System. — Epistaxis, an early symptom, precedes typhoid 
fever more commonly than any other febrile affection. It is occasionally 
profuse and serious. 

Laryngitis is not very common. The ulcers and the perichondritis 
have already been described. (Edema, apart from ulceration, is rare. In 
this country the laryngeal complications of typhoid fever seem much less 
frequent than on the Continent. I have twice seen severe perichondritis; 
both of the cases recovered, one after the expectoration of large portions 
of the thyroid cartilage. 

Keen and Liming have collected 221 cases of serious surgical complica- 
tions of the larynx. General emphysema may follow the perforation of an 
ulcer. Stenosis is a very serious sequence. 

From some recent studies it would appear that paralysis of the laryn- 
geal muscles is much more common than we have supposed. Przedborski 
(Yolkmann's Sammlung, ~No. 182) has systematically examined the larynx 
in 100 consecutive cases and found 25 with paralysis. The condition is 
nearly always due to neuritis, sometimes in connection with affections of 
. other nerves. 

Bronchitis is one of the most frequent initial symptoms. It is indi- 
cated by the presence of sibilant rales. The smaller tubes may be involved, 
producing urgent cough and even slight cyanosis. Collapse and lobular 
pneumonia may also occur. 

Lobar pneumonia is met with under two conditions: 

1. It may be the initial symptom of the disease. After an indisposition 
of a day or so, the patient is seized with a chill, has high fever, pain in the 
side, and within forty-eight hours there are signs of consolidation and the 
evidences of an ordinary lobar pneumonia. The intestinal symptoms may 
not occur until toward the end of the first week or later; the pulmonary 
symptoms persist, crisis does not occur; the aspect of the patient changes, 
and by the end of the second week the clinical picture is that of typhoid 
fever. Spots may then be present and doubts as to the nature of the case 
are solved. In other instances, in the absence of a characteristic eruption, 
the case remains doubtful, and it is impossible to say whether the disease 
has been pneumonia, in which the so-called typhoid symptoms have devel- 
oped, or whether it was typhoid fever with early implication of the lungs. 
This condition may depend upon an early localization of the typhoid bacil- 
lus in the lung. I have twice performed autopsies in cases of this pneumo- 



/ 



28 SPECIFIC INFECTIOUS DISEASES. 

typhus, as it is called by the French and Germans,, and can speak positively 
of its onset with all the symptoms of a frank pneumonia. 

2. Lobar pneumonia forms a serious and by no means infrequent com- 
plication of the second or third week. It was present in over 8 per cent 
of the Munich cases. The symptoms are usually not marked. There may 
be no rusty sputa, and, unless sought for, the condition is frequently over- 
looked. Infarction, abscess, and gangrene are occasionally pulmonary 
complications. 

Hypostatic congestion of the lungs and oedema, due to enfeebled circu- 
lation in the later periods of the disease, are very common. The physical 
signs are defective resonance at the bases, feeble breath-sounds, and, on 
deep inspiration, moist rales. 

Haemoptysis may occur and even prove fatal. 

Pleurisy was present in about 8 per cent of the Munich autopsies. It 
may occur at the outset — pleuro-typhoid — or slowly during convalescence, 
in which case it is almost always purulent and due to the typhoid bacilli. 

Pneumothorax is rare. Hale White has reported two cases, in both 
of which pleurisy existed. The condition may be due to straining, or to 
the rupture of a small pysemic abscess. It may occur also during convales- 
cence. After death, no lesions of the lungs or bronchi were discovered. 
Creagh reports a case in which the haemoptysis caused death. 

Nervous System. — Cerebrospinal Form. — As already noted, the disease 
may set in with intense and persisting headache, or an aggravated form 
of neuralgia. There are cases in which the effect of the poison is mani- 
fested on the nervous system early and with the greatest intensity. There 
are headache, photophobia, retraction of the neck, marked twitchings 
of the muscles, rigidity, and even convulsions. In such cases the diag- 
nosis of meningitis is invariably made. I have examined post mortem three 
such cases, in two of which the diagnosis of cerebro-spinal fever had been ♦ 
made. In not one of them was there any trace of meningeal inflammation, 
only the most intense congestion of the cerebral and spinal pia. Menin- 
gitis, however, may occur, but is extremely rare, as shown by the Munich 
record, in which there were only 11 among the 2,000 cases. With the evi- 
dence obtained by lumbar puncture and the presence or absence of Kernig's 
sign the diagnosis of meningitis is now more easily made. A number of 
genuine eases of meningitis have been reported of late years, and the litera- 
ture is quite fully given by Hofmann * to July, 1900. In at least 10 cases 
the typhoid bacillus has been isolated in pure culture. Marked convulsive 
movements, local or general, with coma and delirium, are seen also in 
thrombosis of the cerebral veins and sinuses. 

Delirium, usually present in very severe cases, is certainly less frequent 
under a rigid plan of hydrotherapy. It may exist from the outset, but 
usually does not occur until the second and sometimes not until the 
third week. It may be slight and only nocturnal. It is, as a rule, a quiet 
delirium, though there are cases in which the patient is very noisy and 
constantly tries to get out of bed, and, unless carefully watched, may es- 



* Deutsche medioinisehe Wochenschrift, July 12, 1900. 



TYPHOID FEVER. 



29 



■cape. The patient does not often become maniacal. In heavy drinkers 
the delirium may have the character of delirium tremens. Even in cases 
which have no positive delirium, the mental processes are usually dulled 
and the aspect is listless and apathetic. In severe cases the patient passes 
into a condition of unconsciousness. The eyes may be open, but he is ob- 
livious to all surrounding circumstances and neither knows nor can indi- 
cate his wants. The urine and faeces are passed involuntarily. In this 
pseudo-wakeful state, or coma vigil, as it is called, the eyes are open and 
the patient is constantly muttering. The lips and tongue are tremulous; 
there are twitchings of the fingers and wrists — subsultus tendinum and 
carphologia. He picks at the bedclothes or grasps at invisible objects. 
These are among the most serious symptoms of the disease and always 
indicate danger. 

Convulsions in typhoid fever are rare. In children they may occur at 
the onset. In September, 1896, a child of ten years was admitted in coma 
following a sudden convulsion after a full meal. This was the starting- 
point of a severe attack of typhoid. Their rarity may be gathered from the 
fact that in 2,960 cases Murchison only met with convulsions in 6. They 
may be associated with an acute encephalitis or with thrombi in the arte- 
ries or in the veins. In the case of my late assistant, Dr. Oppenheimer, the 
convulsions occurred on the eighth day of the fever, and proved fatal 
in twelve hours. Thrombosis of the branches of the left middle cerebral 
artery was found. In other instances, as in one reported by J. W. Moore, 
no brain lesions are found. In very nervous women I have seen hysterical 
convulsions. Five cases are reported in Studies II and III. 

Neuritis, which is not uncommon, may be local, or a widespread affec- 
tion of the nerves of the legs or of both arms and legs. 

Local Neuritis. — This may occur during the height of the fever or after 
convalescence is established. It may set in with agonizing pain, and with 
sensitiveness of the affected nerve trunks. The local neuritis may affect 
the nerves of an arm or of a leg, and involve chiefly the extensors, so that 
there is wrist-drop or foot-drop. The arm or leg may be much swollen 
and the skin over it erythematous. Painful muscles are not uncommon, 
particularly in the calves. I have reported a series of cases (Studies III). 
Painful cramps may also occur. In some of the cases of painful legs the 
condition is a myositis; in others the swelling and pain may be due to 
thrombosis in the deeper veins. 

A curious condition, probably a local neuritis, is that which was first 
described by Handford as tender toes, and which appears to be much more 
common after the cold-bath treatment. The tips and pads of the toes, 
rarely the pads at their bases, become exquisitely sensitive, so that the 
patient can not bear the weight of the bedclothes. There is no discolora- 
tion and no swelling, and it disappears usually within a week or ten days. 

Multiple neuritis in typhoid fever comes on usually during convales- 
cence. The legs may be affected, or the four extremities. The cases arc 
often difficult; to differentiate from those with subacute poliomyelitis. Re- 
covery is the rnle. Of 4 cases with involvement of arms and legs, 3 recov- 
ered completely and 1 improved (Studies II). 



30 



SPECIFIC INFECTIOUS DISEASES. 



Poliomyelitis may occur with the symptoms of acute ascending paral- 
ysis and prove fatal in a few days. More frequently it is less acute, and 
causes either a paraplegia or a limited atrophic paralysis of one arm or leg. 

Hemiplegia is a rare complication. Francis Hawkins has collected 17 
cases from the literature; aphasia was present in 12. The lesion is usually 
thrombosis of the arteries, less often a meningo-encephalitis. The aphasia 
may disappear. Four cases of hemiplegia are given in Studies III. 

True tetany occurs sometimes, and has been reported in connection with 
certain epidemics. It may set in during the full height of the disease. 
The complication is extremely rare in this country, and Janeway, so far as 
I know, has alone reported instances. 

Post-febrile insanity is perhaps more frequent after typhoid than after 
any other disease. Wood regards it as confusional insanity, the result of 
impaired nutrition and exhaustion of the nervous centres. Of 5 cases 
reported in Studies I, 4 recovered. Mental dulness with hesitancy of 
speech and melancholia may follow. The outlook is usually good. 

Special Senses. — Eye. — Conjunctivitis, simple or phlyctenular, some- 
times with keratitis and iritis, may develop. Panophthalmitis has been re^ 
ported in one case in association with haemorrhage (Finlay). Loss of accom- 
modation may occur, usually in the asthenia of convalescence. Oculo-motor 
paralysis has been seen, due probably to neuritis. Retinal haemorrhages 
may occur alone or in association with other liEemorrhagic features. Double 
optic neuritis has been described in the course of the fever. It may be 
independent of meningitis. Atrophy may follow, but these complications 
are excessively rare. Cataract may follow inflammation of the uveal tract. 
Other rare complications are thrombosis of the orbital veins and orbital 
haemorrhage. (See De Schweinitz in Keen's monograph for full considera- 
tion of the subject.) 

Ear. — Otitis media is not infrequent, 2.5 per cent in Hengst's collected 
cases. We have never found the typhoid bacillus in the discharge. Seri- 
ous results are rare; only one case of mastoid disease occurred. The otitis 
may set in with a chill and an aggravation of the fever. 

Eenal System. — Retention of urine is an early symptom and may be the 
cause of abdominal pain. It may recur throughout the attack. Suppres- 
sion of urine is rare. The urine is usually diminished at first, has the 
ordinary febrile characters, and the pigments are increased. Later in the 
disease it is more abundant and lighter in color. 

The Diazo-reaction of Ehrlich. — Two solutions are employed, kept in 
separate bottles: one containing a saturated solution of sulphanilic acid 
in a solution of hydrochloric acid (50 cc. to 1,000 cc); the other a half per 
cent solution of sodium nitrite. To make the test, a few cubic centimetres 
of urine are placed in a small test-tube with an equal quantity of a mix- 
ture of the solution of the sulphanilic acid (40 cc.) and the sodium nitrite 
(1 cc), the whole being thoroughly shaken. One cubic centimetre of am- 
monia is then allowed to flow carefully down the side of the tube, forming 
a colorless zone above the yellow urine, and at the junction of the two a 
deep brownish-red ring will be seen if the reaction is present. With normal 
urine a lighter brownish ring is produced, without a shade of red. The 



TYPHOID FEVER. 



31 



color of the foam of the mixed urine and reagent, and the tint they produce 
when largely diluted with water, are characteristic, being in both cases 
of a delicate rose-red if the diazo-reaction be present; but if not, brownish- 
yellow. It was found in 543 of 796 cases. It may be present previous to 
the occurrence of the rash, and as late as the 'twenty-second day. The value 
of the test is lessened by its occurrence in cases of miliary tuberculosis, in 
malarial fever, and occasionally in the acute diseases associated with high 
fever. The urotoxic coefficient in typhoid fever is high and is said to be 
increased by the tubs. 

Baccilluria occurs in about one third of the cases, caused by the typhoid 
bacilli. The urine may be turbid from their presence and in the test- 
tube give a peculiar shimmer. There may be millions of bacilli to the cubic 
millimetre without pyuria or any symptoms of renal or bladder trouble. 
The bacilli may be present in the urine for years after the attack (see 
Gwyn, Studies III). Of 51 cases during the session of 1900-1901 in my 
clinic, Cole found typhoid bacilli in the urine in 16. 

The renal complications in typhoid fever may be thus grouped: 

(a) Febrile albuminuria is common and of no special significance. It 
was present in 616 of 829 cases, 74 per cent. Tube casts were present in 
391 cases, 47 per cent. 

(o) Acute nephritis at the onset or during the height of the disease 
— the nephro-typhus of the Germans, the fievre typho'ide a forme renale of 
the French — may set in, with all the symptoms of acute Bright 7 s disease, 
masking in many instances the true nature of the malady. After an 
indisposition of a few days there may be fever, pain in the back, and 
the passage of a small amount of bloody urine. 

(c) Nephritis during convalescence is rare, and is usually associated 
with anaemia and oedema. Chronic nephritis is a most exceptional sequel 
of the disease. 

(d) The lymphomatous nephritis, described by E. Wagner, and already 
referred to in the section on morbid anatomy, produces, as a rule, no 
symptoms. 

(e) Pyuria, a not uncommon complication, may be associated with the 
typhoid or the colon bacillus, less often with staphylococci. It disappears 
during convalescence. It is usually due to a simple catarrh of the bladder, 
rarely to an intense cystitis. 

(f) Post-typhoid Pyelitis. — One or both kidneys may be involved, either 
at the height of the disease or during convalescence. There may be blood 
and pus at first, later pus alone, varying in amount. A severe pyelo- 
nephritis may follow. 

Generative System. — Orchitis is occasionally met with. Kinnicutt has 
collected 53 cases in the literature. It is usually associated with a catarrhal 
urethritis. Induration or atrophy may occur, and more rarely suppura- 
tion. It was present in 2 cases in my series, and in a third recent one 
during convalescence. In 1 case double hydrocele developed suddenly 
on the nineteenth day (Dunlap). 

Acute mastitis, which may go on to suppuration, is a rare complication. 
It was present in 2 cases of my series. 



32 



SPECIFIC INFECTIOUS DISEASES. 



Osseous System. — Among the most common and troublesome of the 
sequelae of the disease are the bone lesions. Of 237 cases collected by 
Keen there were periostitis in 110, necrosis in 85, and caries in 13. They 
are, I am sure, much more frequent than the figures indicate. Six cases 
came under my notice in the course of a year, and formed the basis of 
Parsons' paper (Studies II). The legs are chiefly involved. In Keen's 
series the tibia was affected in 91 cases, the ribs in 40. A majority of 
the cases occur after convalescence is established. Of 51 cases in which 
bacteriological examinations were made, in 13 pyogenic bacteria were 
found; in 38 there were typhoid bacilli (Keen). The typhoid bone lesion is 
apt to form what the old writers called a cold abscess. Only a few of the 
cases are acute. Chronicity, indolence, and a remarkable tendency to 
recurrence are perhaps the three most striking features of the typhoid 
bone lesions. If not thoroughly treated sinuses may remain, and typhoid 
bacilli have been found in these old lesions for as long as seven or more 
years. 

Arthritis was present in 5 cases of my series. Eheumatic and septic 
forms are described, as well as a typhoid arthritis proper. The complica- 
tion is exceedingly rare, and yet Keen has collected from the literature 
84 cases. One of the most important points relating to it is the frequency 
with which spontaneous dislocations occur, particularly of the hip. 

Typhoid Spine (Gibney). — During the disease in protracted cases, more 
often during convalescence, the patient complains of pain in the lumbar 
and sacral regions, perhaps after a slight jar or shock. Stiffness of the 
back, pain on movement, and tenderness on pressure are the chief features, 
but there are in addition marked nervous, sometimes hysterical manifes- 
tations. The diagnosis of spondylitis, Pott's disease, or perinephritic ab- 
scess, etc., may be made. The examination is negative. The patient 
is afebrile, as a rule. The outlook is good. In rare instances there may 
be perispondylitis, but usually the condition is a neurosis (Studies I). 

The muscles may be the seat of the degeneration already referred to, 
but it rarely causes any symptoms. Haemorrhage occasionally occurs into 
the muscles, and late in protracted cases abscesses may develop. 

Post-typhoid Septicaemia and Pyaemia. — In very protracted 
eases there may recur after defervescence a slight fever (100°-101°), with 
sweats, which is possibly septic. In other cases for two or three weeks there 
are recurring chills, often of great severity. They are usually of no mo- 
ment in the absence of signs of complication. (See Studies II and III.) 

Typhoid pyaemia is not very uncommon, (a) Extensive furunculosis 
may be associated with irregular fever and leucocytosis. (b) Following 
the fever there may be multiple subcutaneous " cold " abscesses, often with 
a dark, thin bloody pus. A score or more of these may appear in different 
parts. Pratt has isolated the bacillus in pure culture from the subcutane- 
ous abscesses, (c) A crural thrombus may suppurate and cause a wide- 
spread pyaemia, (d) In rare instances suppuration of the mesenteric 
glands, of a splenic infarct, a sloughing parotid bubo, a perinephric or peri- 
rectal abscess, acute necrosis of the bones, or a multiple suppurative ar- 
thritis may cause pyaemia. 



TYPHOID FEVER. 



33 



Association of other Diseases. — Erysipelas is a rare complica- 
tion, most commonly met with during convalescence. In 1,420 cases at 
Basel it occurred 10 times. Griesinger states that it is met with in 2 
per cent. Measles may develop during the fever or in convalescence. 
Chicken-pox and noma have been reported in children. Pseudo-membra- 
nous inflammations may occur in the pharynx, larynx, or genitals. 

Malarial and typhoid fevers may be associated, but a majority of the 
cases of so-called typho-malarial fever are either remittent malarial fever 
or true typhoid. It is interesting to note that among the 829 cases of 
typhoid fever plasmodia were found in the blood during the course of the 
disease in only 1 case. (See Lyon, Studies III.) Many of our typhoid-fever 
cases came from malarious regions. 

Typhoid Fever and Tuberculosis. — (a) The diseases may coexist. In 4 
of my 80 autopsies there were tuberculous lesions, (b) Miliary tuberculosis 
is often mistaken for typhoid fever; they may indeed coexist, (c) Cases 
of pulmonary tuberculosis may begin with a low fever, and features sug- 
gestive of enteric. Cases of this kind have led to the belief that tubercu- 
losis often follows typhoid fever, (d) There are cases of typhoid fever 
with pulmonary or pleuritic symptoms which suggest at the outset tuber- 
culosis. 

In epilepsy and in chronic chorea the fits and movements usually cease 
during an attack, and in typhoid fever in a diabetic subject the sugar may 
be absent during the height of the disease. 

Varieties of Typhoid. — Typhoid fever presents an extremely com- 
plex symptomatology. Many forms have been described, some of which 
present exaggeration of common symptoms, others modification in the 
course, others again greater intensity of action of the poison on certain 
organs. As we have seen, when the nervous system is specially involved, 
it has been called the cerebro-spinal form; when the kidneys are early and 
severely affected, nephro-typhoid; when the disease begins with pulmo- 
nary symptoms, pneumo-typhoid; with pleurisy, pleuro,- typhoid; when the 
disease is characterized throughout by profuse sweats, the sudoral form 
of the disease. It is a mistake, I think, to recognize or speak of these as 
varieties. It is enough to remember that typhoid has no fixed and con- 
stant course, that it may set in occasionally with symptoms localized in 
certain organs, and that many of its symptoms are extremely variable — in 
one epidemic uniform and text-book-like, in another slight or not met with. 
This diversified symptomatology has led to many clinical errors, and in the 
absence of the salutary lessons of morbid anatomy it is not surprising that 
practitioners have so often been led astray. We may recognize with Mur- 
chison the following varieties: 

1. The mild and abortive forms. It is very important for the practi- 
tioner to recognize the mild type of typhoid fever, often spoken of as 
gastric fever or even regarded as simple febricula. In this form, the 
typhus levissimus of Griesinger, the symptoms arc similar in kind but alto- 
gether less intense than in the graver attacks, although the onset may 
be sudden and severe. The temperature rarely readies 103°, and the 
fever of onset may not show the gradual ascending evening record. The 



34 



SPECIFIC INFECTIOUS DISEASES. 



spleen is enlarged, the rose-spots may be marked; often they are very 
few in number. The diarrhoea is variable, often it is not present. In such 
eases the symptoms may persist for from ten to fourteen days. 

In the abortive form the symptoms of onset may be marked with shiv- 
ering and fever of 103° or even higher. The date of onset is often defi- 
nite, a point upon which Jiirgensen lays great stress. Eose-spots may 
occur from the second to the fifth day. Early in the second week or at 
the end of the first week the fever falls, often with profuse sweating, and 
convalescence is established. In this abortive form relapse may occur and 
may occasionally prove severe. When typhoid fever prevails extensively 
these cases are not uncommon. I agree with J. C. Wilson, who states that 
they are not nearly so common in this country as in Europe. 

2. The grave form is usually characterized by high fever and pro- 
nounced nervous symptoms. In this category, too, come the very severe 
cases, setting in with pneumonia and Bright's disease, and with the very 
intense gastro-intestinal or cerebro-spinal symptoms. 

3. The latent or ambulatory form of typhoid fever, which is particu- 
larly common in hospital practice. The symptoms are usually slight, 
and the patient scarcely feels ill enough to go to bed. He has languor, 
perhaps slight diarrhoea, but keeps about and may even attend to his work 
throughout the entire attack. In other instances delirium sets in. The 
worst cases of this form are seen in sailors, who keep up and about, though 
feeling ill and feverish. When brought to the hospital they often have 
symptoms of a most severe type of the disease. Haemorrhage or perfora- 
tion may be the first marked symptom of this ambulatory type. Sir W. 
Jenner has called attention to the dangers of this form, and particularly 
to the grave prognosis in the case of persons who have travelled far with 
the disease in progress. 

Hoemorrliagic Typhoid Fever. — This is excessively rare. Among Ous- 
kow ? s 6,513 cases there were 4 fatal cases with general hemorrhagic fea- 
tures. Only one instance was present in our 829 cases. Haemorrhages 
may be marked from the outset, but more commonly they come on during 
the course of the disease. The condition is not necessarily fatal. Our 
case recovered, as did several of those reported by Nicholls from the Eoyal 
Victoria Hospital, Montreal. (See Hamburger, Studies III.) 

An afebrile typhoid fever is recognized by authors. Liebermeister says 
that the cases were not uncommon at Basel. The patients presented las- 
situde, depression, headache, furred tongue, loss of appetite, slow pulse, 
and even the spots and enlarged spleen. I have seen the temperature 
normal on the sixteenth day, while the spots did not come out until later. 

Typhoid Fever ill Children. — Cases are not uncommon under the age 
of ten, but the disease is rare in infants under two years of age. Cases 
have been reported, however, in sucklings (nine months, Fuller; four and 
a half months, Ogle), and perforation has been met with in an infant five 
days old. Epistaxis rarely occurs; the rise in temperature is less gradual; 
the initial bronchial catarrh is often observed. The nervous s} 7 mptoms maj T 
be prominent; there are wakefulness and delirium; diarrhoea is often ab- 
sent. The rash may be very slight, but the most copious eruption I have 



TYPHOID FEVER. 



35 



ever seen was in a child of eight. The abdominal symptoms are often 
mild. Fatal haemorrhage and perforation are rare. Among the sequelae, 
aphasia, noma, and bone lesions may be mentioned as more common in 
children than in adnlts. The mortality of typhoid fever in children is 
low. In cases fatal early in the disease only a careful bacteriological 
examination can decide whether the swollen Peyer's patches and mesen- 
teric glands — not uncommon in children with fever— depend upon infec- 
tion with typhoid bacilli. 

Typhoid Fever in the Aged. — After the fortieth year the disease runs a 
less favorable course, and the mortality is very high. Of 63 fatal cases, 
7 were over forty years of age; 1 was aged sixty-three, another seventy. 
The fever is not so high, but complications are more common, particu- 
larly pneumonia and heart-failure. 

Typhoid Fever in Pregnancy. — Pregnancy affords no immunity against 
typhoid. In 1,079 of our cases to Jan. 1, 1901, 289 of which were females, 
there were 4 cases. Goltdammer noted 26 pregnancies in 600 cases of 
typhoid fever in the female. It is more commonly seen in the first half 
of pregnancy. The pregnancy is interrupted in about 65 per cent of the 
cases, usually in the second week of the disease. Of 310 cases, abortion 
or premature delivery occurred in 199. In 233 of these cases the ma- 
ternal mortality was 37, or 16 per cent. Pregnancy has not been found 
to be a contra-indication to the cold bath. Dobbin (Studies III) reports 
a remarkable case of puerperal infection with bacillus typhosus, and a 
similar case has been recorded by Blumer. 

Typhoid Fever in the Foetus. — From the recent studies of Fordyce, 
J. I. Morse, and F. W. Lynch, we may conclude that the typhoid bacillus 
may pass through the placenta to the child, causing a typhoid septicaemia, 
without intestinal lesions. Lynch has recently collected 16 such cases. 
Infection of the foetus does not necessarily follow, but when infected the 
child dies, either in utero or shortly after birth. The Widal reaction has 
been obtained with foetal blood. Its presence does not indicate that the 
child has survived infection in utero, as the agglutinating substances may 
filter through the placenta. They may also be transmitted to the nursling 
through the milk, and cause a transient reaction. The reaction could not 
be obtained with foetal blood from which typhoid bacilli were cultivated 
(Lynch). 

Relapse. — Relapses vary in frequency in different epidemics, and, it 
would appear, in different places. The percentages of different authors 
range from 3 per cent (Murchison), 11 per cent (Baumler), to 15 or 18 
per cent (Immermann). In Wagner's clinic, from 1882 to 1886, there were 
49 relapses in 561 cases. In 829 cases there were 86 relapses, 10.3 per 
cent. 

We may recognize the ordinary, the intercurrent, and the spurious re- 
lapse. 

The ordinary relapse sets in after complete defervescence. The average 
duration of the interval in living's eases was a little over five days. 

In one of my cases there was complete apyrexia for twenty-three days, 
followed by a relapse of forty-one days' duration; then apyrexia for forty- 



36 



SPECIFIC INFECTIOUS DISEASES. 



two days, followed by a second relapse of two weeks' duration. As a rule, 
two of the three important symptoms — step-like temperature at onset, rose- 
ola, an enlarged spleen — should be present to justify the diagnosis of a re- 
lapse. The intestinal symptoms are variable. The onset may be abrupt with 
a chill, or the temperature may have a typical ascent, as shown in 
Chart I. The number of relapses range from 1 to 5. Da Costa twice saw 5 
relapses. The attack is usually less severe and of shorter duration. Of 
Murchison's 53 cases, the mean duration of the first attack was about 
twenty-six days; of the relapse, fifteen days. The mortality of relapse 
cases is not high. 

The intercurrent relapse is common, often most severe, and is respon- 
sible for a great many of the most protracted cases. The temperature 
drops and the patient improves; but after remaining between 100° and 
102° for a few days, the fever again rises and the patient enters upon 
another attack, which may be even more protracted, and of much greater 
intensity than the original one. 

Spurious relapses are very common. They have already been referred 
to on page 16, under post-typhoid elevations of temperature. They are 
recrudescences of the fever due to a number of causes. It is not always 
easy to determine whether a relapse is present, particularly in cases in 
which the fever persists for only five or seven days without rose-spots and 
without enlargement of the spleen. 

The relapse shows a reinfection from within, but of the conditions fa- 
voring its occurrence we as yet know little. Errors in diet are sometimes 
held responsible and occasionally the rise in temperature follows abruptly 
upon some indiscretion. Immunity in typhoid is acquired slowly, and we 
know that even for a long period after the fever has disappeared the ty- 
phoid bacilli may be found in the stools, in the spleen, and in the mesen- 
teric glands. Chiari suggests that the reinfection may be associated with 
the persistence of bacilli in the bile-passages; an indiscretion in diet may 
cause their discharge into the intestine. 

Diagnosis. — There are several points to note. In the first place, ty- 
phoid fever is the most common of all continued fevers. Secondly, it is 
extraordinarily variable in its manifestations. Thirdly, there is no such 
hybrid malady as typho-malarial fever. Fourthly, errors in diagnosis are 
inevitable, even under the most favorable conditions. Lastly, let the 
" cock-sure " physician, who never makes mistakes, read the Keport of the 
United States Army Commission on Typhoid Fever during the Spanish- 
American War. 

Data for Diagnosis. — (a) General. — ~No single symptom or feature is 
characteristic. The onset is often suggestive, particularly the occurrence 
of epistaxis, and (if seen from the start) the ascending fever. The steadi- 
ness of the fever for a week or longer after reaching the fastigium is an 
important point. The irregular remittent character in the third week 
and the intermittent features with chills are common sources of error. 
While there is nothing characteristic in the pulse, dicrotism is so much 
more common early in typhoid fever that its presence is always suggestive. 
The rash is the most valuable single sign, and with the fever usually 



TYPHOID FEVER. 



37 



clinches the diagnosis. The enlarged spleen is of less importance, since 
it occurs in all febrile conditions, but with the fever and the rash it com- 
pletes a diagnostic triad of the disease. The absence of leucocytosis and 
the presence of Ehrlich's reaction are valuable accessory signs. 

(b) Specific. — (1) Isolation of Typhoid Bacilli from the Blood. — New 
methods have given better results in this procedure. Cole has recently 
isolated the organisms in 12 cases in my wards, in 6 before the Widal 
was positive. The method is exceedingly valuable in the acute septic forms. 
The hypodermic puncture of a vein for the blood causes little or no pain. 

(2) Isolation of Typhoid Bacilli from the Stools. — Cultures from the 
stools by the methods of Eisner, His, and especially Piorkowski, have, in 
the hands of some observers, proved of diagnostic value. The difficulties, 
however, are considerable and results not certain. 

(3) Isolation of Typhoid Bacilli from the Urine. — Neumann, Horton- 
Smith, Eichardson, and Gwyn have shown the great frequency of typhoid 
bacilli in the urine. In some cases they may be obtained before the Widal 
test is positive. Eoutine cultures do not offer great difficulties, and may 
frequently be of diagnostic value. 

(4) Isolation of Typhoid Bacilli from the Rose-spots. — Neufeld, Cursch- 
mann, and Richardson have demonstrated the presence of the bacilli in 
rose-spots in 32 of 40 cases examined. As the procedure causes consider- 
able discomfort it can not be used as a routine method. 

(5) The Agglutination Test. — In 1894 Pfeiffer showed that cholera 
spirilla, when introduced into the peritonaeum of an immunized animal, 
or when mixed with the serum of immunized animals, lose their motion 
and break up. This " Pfeiffer's phenomenon " of agglutination and im- 
mobilization was thoroughly studied by Durham and also by A. S. Griin- 
baum, and the specificity of the reaction demonstrated. Widal took the 
method, and made it available in clinical work. 

Methods. — (a) Macroscopic or Sloiv Method. — The difficulties are not 
compensated for by its supposed greater reliability, and it is not in gen- 
eral use in this country or in England. 

(b) Microscopic or Rapid Method. — The serum is mixed with a young 
bouillon culture of the typhoid bacillus, or with a suspension of a young 
agar culture, in such a manner as to dilute the serum to the required 
degree. A hanging-drop preparation of the mixture is made, and if the 
reaction is positive the bacilli will within a given time lose their motility 
and collect in clumps. Wyatt Johnston introduced the use of dried blood. 
It is convenient, but does not permit accurate dilutions. The use of glass 
bulbs to obtain the scrum, and small glass pipettes to make accurate dilu- 
tions, is of value. As Cabot says, "the test is a quantitative, not a quali- 
tative, one." Both the degree of dilution and the time limit are of im- 
portance. A safe standard, and the one in use at the Johns Hopkins Hos- 
pital, is a dilution of 1-50 and a time limit of one hour. 

Results. — Cabot's collection of 5,97 8 cases gives a positive reaction in 
97.2 per cent. A positive reaction was obtained in 93 per cent of 849 eases 
tested before the eighth day. It may not appear until the relapse. In 
4 of my cases it developed on the twenty-second, twenty-sixth, thirty-fifth, 
3 . 



3S 



SPECIFIC INFECTIOUS DISEASES. 



and forty-second days, respectively. It may be present even twenty or 
thirty years subsequent to the attack of fever. 

While on the whole the serum reaction is of very great value, there 
are certain difficulties and objections which must be considered. A per- 
fectly characteristic case with haemorrhages, rose-spots, etc., may give 
no reaction throughout. In other eases the reaction is much delayed, 
becoming positive only during convalescence, or even during a relapse.* 

Common Soukces of Error in Diagnosis. — An early and intense 
localization of the infection in certain organs may give rise to doubt 
at first. 

Cases coming on with severe headache, photophobia, delirium, twitching 
of the muscles and retraction of the head are almost invariably regarded as 
cerebrospinal meningitis. Under such circumstances it may for a few 
days be impossible to make a satisfactory diagnosis. I have thrice per- 
formed autopsies on cases of this kind in which no suspicion of typhoid 
fever had been present, the intense cerebro-spinal manifestations having 
dominated the scene. Until the appearance of abdominal symptoms, or 
the rash, it may be quite impossible to determine the nature of the case. 
Cerebro-spinal meningitis is, however, a rare disease; typhoid fever a A^ery 
common one, and the onset with severe nervous symptoms is by no means 
infrequent. Fully one half of the cases of so-called brain-fever belong to 
this category. The lumbar puncture is now a great help. 

I have already spoken of the misleading pulmonary symptoms, which 
occasionally develop at the very outset of the disease. The bronchitis 
rarely causes error, though it may be intense and attract the chief atten- 
tion. More difficult are the cases setting in with chill and followed rapidly 
by pneumonia. I have brought such a case before the class one week as 
typical pneumonia, and a fortnight later shown the same case as undoubt- 
edly one of typhoid fever. In another case, in which the onset was with 
definite pneumonia, no spots developed, and, though there were diarrhoea, 
meteorism, and the most pronounced nervous symptoms, the doubt still 
remains whether it was a case of typhoid fever or one of pneumonia in 
which severe secondary symptoms developed. There is less danger of 
mistaking the pneumonia which develops at the height of the disease, and 
yet this is possible, as in a case admitted a few years ago to my wards — 
a man aged seventy, insensible, with a dry tongue, tremor, ecchymoses 
upon the wrists and ankles, no rose-spots, enlargement of the spleen, and 
consolidation of his right lower lobe. It was very natural, particularly 
since there was no history, to regard such a case as senile pneumonia with 
profound constitutional disturbance, but • the autopsy showed the char- 
acteristic lesions of typhoid fever. Early involvement of the pleura or the 
kidneys may for a time obscure the diagnosis. 

Of diseases with which typhoid fever may be confounded, malaria, cer- 
tain forms of pyaemia, acute tuberculosis, and tuberculous peritonitis are 
the most important. 

* There seems to be a minimum of risk in working with typhoid cultures and in work- 
ing at the Widal reaction. I know of no case in which the disease has been contracted 
directly from this source. 



TYPHOID FEVER. 



39 



From malarial fever, typhoid is, as a rule, readily recognized. There 
is no such disease as typho-malarial fever — that is, a separate and distinct 
malady. Typhoid fever and malarial fever may coexist in the same patient. 
Of 829 cases of typhoid fever, in only a single instance were the malarial 
parasites found in the blood during the fever. In patients returning from 
Cuba and Porto Eico during the late war the two conditions were often 
found together, but in this country it is excessively rare. The term typho- 
malarial fever should be abandoned, and doctors should stop the falsifi- 
cation of vital statistics by death certificates signed with this diagnosis. 
The principle is bad and the practice is worse, since it gives a false sense 
of security, and may prevent proper measures of prophylaxis. The au- 
tumnal type of malarial fever may present a striking similarity in its early 
days to typhoid fever. Differentiation may be made only by the blood 
examination. There may be no chills, the remissions may be extremely 
slight, there is a history perhaps of malaise, weakness, diarrhoea, and some- 
times vomiting. The tongue is furred and white, the cheeks flushed, 
the spleen slightly enlarged, and the temperature continuous, or with very 
slight remissions. The agstivo-autumnal variety of the malarial parasite 
may not be present in the circulating blood for several days. Every year 
we have one or two cases in which- the diagnosis is in doubt for a few 
days. 

Pycvmia. — The long-continued fever of obscure, deep-seated suppura- 
tion, without chills or sweats, may simulate typhoid. The more chronic 
cases of ulcerative endocarditis are usually diagnosed enteric fever. The 
presence or absence of leucocytosis is an important aid. The Widal reac- 
tion and the blood cultures now offer additional and valuable help. 

Acute miliary tuberculosis is not infrequently mistaken for typhoid 
fever. The points in differential diagnosis will be discussed under that 
disease. Tuberculous peritonitis in certain of its forms may closely simu- 
late typhoid fever, and will be referred to in another section. 

The early abdominal pain, etc., may lead to the diagnosis of appendi- 
citis. (See Appendicitis.) 

Prognosis. — (a) Death-rate. — The mortality is very variable, ranging 
in private practice from 5 to 12 and in hospital practice from 7 to 20 per 
cent. In some large epidemics the death-rate has been very low. In the 
recent outbreak at Maidstone, England, it was between 7 and 8 per cent. 
In recent years the deaths from typhoid fever have certainly diminished, 
and, under the influence of Brand, the reintroduction of hydrotherapy 
has reduced the mortality in institutions in a remarkable manner, even 
as low as 5 or 6 per cent. Of the 829 cases treated to May 15, 1899, in 
my wards, 7.5 per cent died. The Metropolitan Fever Hospitals still 
show a high rate of mortality — about 17 per cent — and Dreschfeld gives 
17.18 per cent as the death-rate in the Monsall Fever Hospital for the ten 
years ending 1894. The mortality in the Spanish-American War was very 
low — 7 per cent — and may be attributed to the picked set of men and to tin 1 
care and attention which the patients received. In South Africa the 
mortality was 20.9 per cent to March 31, 1901. 

(b) Special Features in Prognosis. — Unfavorable symptoms are high 



40 



SPECIFIC INFECTIOUS DISEASES. 



fever, toxic symptoms with delirium, meteorism, and haemorrhage. Fat 
subjects stand typhoid fever badly. The mortality in women is greater 
than in men. The complications and dangers are more serious in the am- 
bulatory form in which the patient has kept about for a week or ten days. 
Early involvement of the nervous system is a bad indication; and the low, 
muttering delirium with tremor means a close fight for life. Prognostic 
signs from the fever alone are deceptive. A temperature above 104° may 
be well borne for many days if the nervous system is not involved. 

(c) Sudden Death. — It is difficult in many cases to explain this most 
lamentable of accidents in the disease. There are cases in which neither 
cerebral, renal, nor cardiac changes have been found; there are instances 
too in which it does not seem likely that there could have been a special 
localization of the toxins in the pneumogastric centres. McPhedran, in 
reporting a case of the kind, in which the post mortem showed no ade- 
quate cause of death, suggests that the experiments of Mc William on sud- 
den cardiac failure probably explain the occurrence of death in certain of 
the cases in which neither embolism nor uraemia is present. Under condi- 
tions of abnormal nutrition there is sometimes induced a state of delirium 
cordis, which may develop spontaneously, or, in the case of animals, on 
slight irritation of the heart, with the result of extreme irregularity and 
finally failure of action. Sudden death occurs more frequently in men 
than in women, according to Dewevre's statistics, in a proportion of 114 to 
26. It may occur at the height of the fever, and, as pointed out by Graves, 
may also happen during convalescence. 

Prophylaxis. — In cities the prevalence of typhoid fever is directly 
proportionate to the inefficiency of the drainage and the water-supply. 
With the improvement in drainage the mortality in many cities has been 
reduced one half or even more. Childs has recently reviewed the sanitary 
history of Munich as far as typhoid fever is concerned. The annual mean 
death-rate per 100,000 inhabitants was from 1851 to 1860, 202.4; from 
1861 to 1870, 147.8; from 1871 to 1880, 116.7; from 1881 to 1890, 16; from 
1891 to 1896, 5.6. 

By most rigid methods of disinfection much may be done to prevent 
the spread of infection. The recent work on the frequency of typhoid 
bacilli in the excretions, especially in the urine, shows that every case is 
a source of real and very serious danger to the community. To carry out 
effective measures of prophylaxis is quite as much a part of the physician's 
duty as the care of the patient. He should recognize that every one in the 
household has probably been exposed to the same source of infection as the 
patient, and he should try to discover the source and advise means of 
guarding against it. The following regulations are observed by the nurses 
in the Johns Hopkins Hospital: 

Dishes must be isolated, washed and dried separately, and boiled daily. 
Thermometers must be isolated, kept in bichloride (1-1,000), which must be 
renewed daily. Linen, when soiled, must be soaked in carbolic (1-20) for 
two hours before sending to the laundry. Stools must be thoroughly mixed 
with an equal amount of milk of lime, and allowed to stand one hour. 
Urine must be mixed with an equal amount of carbolic (1-20), and allowed 



TYPHOID FEVER. 



41 



to stand one hour. Bed-pans and urinals must be isolated and scalded 
after each time of using. Syringes and rectal tubes must be isolated and 
the latter boiled after using. Tubs should be scrubbed daily; canvases 
changed daily, and soaked in carbolic as the linen is. Rands must be 
scrubbed and disinfected after giving tubs or working over typhoid-fever 
patients. Blankets, mattresses, and pillows must be sterilized after use in 
steam sterilizer. 

Preventive Inoculation. — Following the work of Haffkine in vaccina- 
tion against cholera, Wright, of Netley, has introduced a similar method 
of vaccination against typhoid. The material used is a bouillon culture 
of bacillus typhosus of high virulence, heated until all organisms are dead. 
The amount inoculated should " be such a quantity which, if injected alive, 
would be fatal to a 350 gm. guinea-pig." The inoculation is followed by 
local tenderness and congestion, faintness, possibly nausea, fever, and rest- 
lessness. Usually all symptoms have disappeared after twenty-four hours. 
It is recommended that the procedure be repeated in two weeks. Follow- 
ing the injection there is an increase in the bactericidal power of the 
blood, and also a very marked increase in the agglutinating power, which 
may persist for at least two years, as in cases reported by Foulerton. This 
procedure has been tried on a large scale in India, and also in the South 
African War. Full statistics from South Africa are not yet available, but 
out of 1,705 persons inoculated at Ladysmith, only 2 per cent were attacked, 
whereas of 10,529 not inoculated, 14 per cent were attacked, and of those 
inoculated the mortality was .0.46 per cent; of those not inoculated the mor- 
tality was 3 per cent. On the whole the experience so far is strongly in 
favor of inoculation. 

When epidemics are prevalent the drinking-water and the' milk used in 
families should be boiled. Travellers should drink light wines or mineral 
water rather than ordinary water or milk. Care should be taken to thor- 
oughly cook oysters which have been fattened or freshened in streams con- 
taminated with sewage. 

While in camps it is easy to boil and filter the water; with troops on 
the march it is a very different matter, and it is impossible to restrain 
men from relieving their thirst the moment they reach water. Various 
chemical methods have been recommended — the use of bromine, hypo- 
chlorite of lime, permanganate of potassium, and the tablets of sodium 
bisulphate, none of which are probably very satisfactory. 

Treatment.— (a) General Management —The profession was long in 
learning that typhoid fever is not a disease to be treated mainly with 
drugs. Careful nursing and a regulated diet are the essentials in a ma- 
jority of the cases. The patient should be in a well-ventilated room (or in 
summer out of doors during the day), strictly confined to bed from the out- 
set, and there remain until convalescence is well established. The bed 
should be single, not too high, and the mattress should not be too hard. 
The woven wire bed, with soft hair mattress, upon which are two folds 
of blanket, combines the two great qualities of a sick-bed, smoothness 
and elasticity. A rubber cloth should he placed under the sheet. An intel- 
ligent nurse should be in charge. When this is impossible, the attending 



42 



SPECIFIC INFECTIOUS DISEASES. 



physician should write out specific instructions, regarding diet, treatment 
of the discharges, and the bed-linen. 

(b) Diet. — Those forms of food should be given which are digested with 
the greatest ease, and which leave behind the smallest amount of residue 
to form faeces. Some regard should be paid to the fancies of the patient. 
Milk is the most suitable food. If used alone, three pints at least may be 
given to an adult in twenty-four hours, always diluted with water, lime- 
water, or aerated waters. Partially peptonized milk, when not distasteful 
to the patient, is occasionally serviceable. The stools of a patient on a 
strict milk diet should be examined with great care, to see if the milk is 
entirely digested. Fever patients often receive more than they can utilize 
in which case masses of curds are seen in the stools, or microscopically fat- 
corpuscles in extraordinary abundance. Under these circumstances it is 
best to substitute, for part of the milk, mutton or chicken broths, or beef- 
juice, or a clear consomme, all of which may be made very palatable by the 
addition of fresh vegetable juices. If, however, diarrhoea exists, animal 
broths are apt to aggravate it. Some patients will take whey, butter- 
milk, kumyss, or matzoon when the ordinary milk is distasteful. Thin 
barley-gruel, well strained, is an excellent food for typhoid-fever patients. 
Eggs may be given, either beaten up in milk or, better still, in the form of 
albumen-water. This is prepared by straining the whites of eggs through 
a cloth and mixing them with an equal quantity of water. It may be flav- 
ored with lemon, and, if the patient is taking spirits, whisky or brandy is 
very conveniently given with it. Patients who are unable to take milk can 
subsist for a time on this alone. The whole egg beaten up in milk or water 
may be used. 

The patient should be given water freely, which may be pleasantly cold. 
Iced tea, barley-water, or lemonade may also be used, and there is no objec- 
tion to coffee or cocoa in moderate quantities. Fruits are not, as a rule, 
allowable, though the juice of lemon or orange may be given. Typhoid 
patients should be fed at stated intervals through the day. At night it 
depends upon the general condition of the patient whether he should be 
aroused from sleep or not. In mild cases it is not well to disturb the 
patient. When there is stupor, however, the patient should be roused for 
food at the regular intervals night and day. 

Alcohol is not necessary in all cases, but may be given when the weak- 
ness is marked, the fever high, and the pulse failing. In young healthy 
adults, without nervous symptoms and without very high fever, it is not 
required; but when the heart-beat is feeble and the first sound becomes 
obscure, if there are a muttering delirium, subsultus tendinum, and a dry 
tongue, brandy or whisky should be freely given. In such a case from 
eight to twelve ounces of good whisky in the twenty-four hours is a moder- 
ate amount. 

It is possible that we give too much food. Inglis has shown that cases 
do very well on cold water alone. The outcry against milk in some quarters 
is, I am sure, unfounded. It causes less intestinal fermentation than any 
other food; it rarely disagrees when diluted, and when alternated with 
egg-albumen forms the ideal diet for typhoid patients. 



TYPHOID FEVER. 



43 



(c) Hydrotherapy. — The use of water, inside and outside, was no new 
treatment in fevers at the end of the last century, when James Currie (a 
friend of Burns and the editor of his poems), wrote his Medical Eeports on 
the Effects of Water, Cold and Warm, as a Eemedy in Fevers and other Dis- 
eases. In this country it was used with great effect and recommended 
strongly by Nathan Smith, of Yale. Since 1861 the value of bathing in 
fevers has been specially emphasized by the late Dr. Brand, of Stettin. 

Hydrotherapy may be carried out in several different ways, of which,, 
in typhoid fever, the most satisfactory are by sponging, the wet pack, and 
the full bath. 

(a) Cold Sponging. — The water may be tepid, cold, or ice-cold, according 
to the height of the fever, A thorough sponge-bath should take from 
fifteen to twenty minutes. The ice-cold sponging is quite as formidable 
as the full cold bath, for which, when there is an insuperable objection 
in private practice, it is an excellent alternative. But frequently it is 
difficult to get the friends to appreciate the advantages of the sponging. 
When such is the case, and in children and delicate persons, it can be 
made a little less formidable by sponging limb by limb and then the back 
and abdomen. 

(b) The cold pack is not so generally useful in typhoid fever, but in 
cases with very pronounced nervous symptoms, if the tub is not available, 
the patient may be wrapped in a sheet wrung out of water at 60° or 65% 
and then cold water sprinkled over him with an ordinary watering-pot. 

(c) The Bath. — The tub should be long enough so that the patient can 
be completely covered except his head. Our rule for some years has been 
to give a bath at 70° every third hour when the temperature was above - 
102.5°. The patient remains in the tub for fifteen or twenty minutes, is 
taken out, wrapped in a dry sheet, and covered with a blanket. While in 
the tub the limbs and trunk are rubbed thoroughly, either with the hand 
or with a suitable rubber. It is well to give the first one or two baths at 

a temperature of 80° or 85°. There is no routine temperature. If the 
bath at 70° is not well taken, raise the temperature to 75° or 80°. It is 
important to see that the canvas supports are properly arranged, and that 
the rubber pillow is comfortable for the patient's head. The first bath 
should not be given at night, and it should be superintended by the house- 
physician. The amount of complaint made by the patient is largely de- 
pendent upon the skill and care with which the baths are given. Food 
is usually given, sometimes a stimulant, after the bath. The blueness and 
shivering, which often follow the bath, are not serious features. The rectal 
temperature is taken immediately after the bath, and again three-quarters 
of an hour later. Contra-indications are peritonitis, haemorrhage, phlebitis, 
severe abdominal pain, and great prostration. The accompanying charl 
(Chart IV) shows the number of baths and the influence on the fever dur- 
ing two days of treatment. The good effects of the baths are: (1) The 
reduction of the fever; (2) the intellect becomes clearer, the stupor lessens, 
and the muscular twitchings disappear; (3) a general tonic action on the 
nervous system and particularly on the heart; ( 1) insomnia is Lessened, the 
patient usually falling asleep for two or three hours after each bath; and 



44 



SPECIFIC INFECTIOUS DISEASES. 



(5), most important of all, the mortality is, under' this plan of treatment, 
reduced to a minimum. 

The spongings frequently have to be substituted for the tubs in cases 
of extreme weakness, or when there is much meteorism, or when there is 
marked collapse after the baths. While a temperature at 70° is usually 
well borne, in the case of children and delicate persons the luke-warm bath 
gradually cooled may be employed. 



Ju ne a 15 ig_ 



Temp. 






























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108 




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Chart IV. 



The results of hydrotherapy are very gratifying. By it in general hos- 
pitals from 6 to 8 patients in every hundred cases are saved. In institu- 
tions in which the expectant or other plans of treatment are employed, 
there is a mortality of from 12 to 15 per cent. In many it is as high as 17 
per cent. There is a remarkable uniformity in the death-rate in hospitals 
which carry out hydrotherapy. During the first ten years to May 15, 1899, 
there have been treated in my wards 829 cases of typhoid fever with a total 
mortality of 7.5 per cent. This includes all cases, those admitted and dying 
within twenty-four or forty-eight hours, and those in which the diagnosis 
was only made at autopsy.* Still more striking by contrast are the figures 
published by F. E. Hare from the Brisbane Hospital (Practitioner, Sep- 
tember, 1897). Of 1,828 cases treated on the general or expectant plan, 

* From May, 1889, when the hospital was opened, to July, 1890, the ordinary expectant 
plan was followed. 



TYPHOID FEVER. 



45 



the mortality was 14.8 per cent. Of 1,902 cases treated since the intro- 
duction of hydrotherapy, the mortality was only 7.5 per cent. Equally 
good results have been obtained by J. C. Wilson and Tyson in Philadelphia, 
by Gilman Thompson in New York, and at numerous hospitals in Germany 
and France. The important question comes up whether the serious com- 
plications of the disease are increased by hydrotherapy. My own statistics 
bear out Hare's that the remarkable life-saving in hydrotherapy does not 
depend upon a diminution in the number of fatal cases from perforation 
or from haemorrhage. The percentage of perforation cases in my series 
was 2.7, which is under the average. At Brisbane it was 2.9 per cent, both 
before and after the introduction of bathing. Haemorrhage occurs in from 
3 to 5 per cent of the cases. In my series it occurred in 6 per cent of all 
cases since the introduction of hydrotherapy. The Brisbane statistics give 
before the introduction of hydrotherapy 1.8 per cent of fatal cases, and 
after the introduction 1.2 per cent. A careful study of the recent statistics 
shows that neither perforation nor haemorrhage is more frequent with 
hydrotherapy. As to relapse, it is more difficult to speak, the percentage 
varies so widely — from 3 to 16. It must be remembered that more cases 
are saved to have relapse. My percentage of 10 is somewhat above the 
average, but the increase in the relapses is not so great as to seriously im- 
pugn the treatment. Hydrotherapy does not probably shorten the duration 
of the stay in hospital, which was forty-two days in my series. We do not, 
however, send out our typhoid cases until they are quite strong and well. 

(d) Medicinal Treatment. — In hospital practice medicines are not often 
needed. A great majority of my cases do not receive a dose. In private 
practice it may be safer, for the young practitioner especially, to order a 
mild fever mixture. The question of medicinal antipyretics is important: 
they are used far too often and too rashly in typhoid fever. An occasional 
dose of antifebrin or antipyrin may do no harm, but the daily use of these 
drugs is most injurious. Quinine in moderate doses is still much em- 
ployed. The local use of guiacol on the skin, 3ss painted on the flank, 
causes a prompt' fall in the temperature. 

Antiseptic Medication. — Very laudable endeavors have been made in 
many quarters to introduce methods of treatment directed toward the 
destruction of the typhoid bacilli, or the toxic agent which they produce, 
but so far without success. Good results have been claimed from the car- 
bolic acid and iodine treatment. Others advocate corrosive sublimate or 
calomel, /3-naphthol, the salicin preparations and guiacol. I can testify 
to the inefficiency of the carbolic acid and iodine and of the /3-naphthol. 
With the mercurial preparations I have no experience. Fortunately for 
the patients, a majority of these medicines meet one of the two objects 
which Hippocrates says the physician should always have in view — they do 
no harm. Irrigation of the colon has been recommended, with a view to 
washing out the toxic matters (Mosler, Seibert). 

(e) Eliminative and Antiseptic Treatment. — Thistle and others have 
advocated a combined eliminative and antiseptic treatment. To aid in 
the elimination of the poison the skin and kidneys are kept active by 
the use of large quantities of water, which is certainly an excellent prac- 



46 



SPECIFIC INFECTIOUS DISEASES. 



tice. Of the various antiseptics employed it is doubtful if any have the 
slightest action on the bacilli in the lymphatic tissues of the bowel. If, 
as - in cholera, the bacilli developed and produced the poison in the in- 
testinal contents, there might be some reasonableness in this method, 
but the bacilli multiply in the intestinal walls, in the mesenteric glands, 
and in the spleen. They are sometimes not found in the stools until 
the end of the second week. The systematic use of purgatives is, in 
my opinion, very bad practice. No one feature in the disease is, I think, 
more serious than persistent diarrhoea. The preliminary calomel purge, 
so much used, is not necessary. Graves remarked that patients who escaped 
active purgation before admission to the hospital usually had much less 
bowel trouble. 

(/) Serum Therapy. — In spite of many experiments and clinical trials 
the results are still unsatisfactory. An antityphoid serum has been 
placed on the market, and a few cases have been reported with rapid im- 
provement. 

(g) Treatment of the Special Symptoms— The abdominal pain and 
tympanites are best treated with fomentations or turpentine stupes. The 
latter, if well applied, give great relief. Sir William Jenner used to lay 
great stress on the advantages of a well-applied turpentine stupe. He 
directed it to be applied as follows: A flannel roller was placed beneath 
the patient, and then a double layer of thin flannel, wrung out of very hot 
water, with a drachm of turpentine mixed with the water, was applied to 
the abdomen and covered with the ends of the roller. 

The meteorism is a difficult and distressing symptom to treat. When 
the gas is in the large bowel, a tube may be passed or a turpentine enema 
given. For tympanites, with a dry tongue, turpentine was extensively 
used by the older Dublin physicians, and it was introduced into this coun- 
try by the late George B. Wood. Unfortunately, it is of very little service 
in the severer cases, which too often resist all treatment. Sometimes, if 
beef-juice and albumen-water are substituted for milk, the distension 
lessens. Charcoal, bismuth, and /?-naphthol may be tried. 

For the diarrhoea, if severe — that is, if there are more than three or 
four stools daily — a starch and opium enema may be given; or, by the 
mouth, a combination of bismuth, in large doses, with Dover's powder; or 
the acid diarrhoea mixture, acetate of lead (grs. 2), dilute acetic acid 
( TU 15-20), and acetate of morphia (gr. |~|). The stools should be exam- 
ined to see that the diarrhoea is not aggravated by the presence of curds. 

Constipation is present in many cases, and though I have never seen it 
do harm, yet it is well every third or fourth day to give an ordinary enema. 
If a laxative is needed during the course of the disease, the Hunyadi- 
janos or Friedrichshall water may be given. 

Hemorrhage from the bowels is best treated with full doses of acetate 
of lead and opium. As absolute rest is essential, the greatest care should 
be taken in the use of the bed-pan. It is perhaps better to allow the pa- 
tient to pass the motions into the draw-sheet. Ice may be freely given, and 
the amount of food should be restricted for eight or ten hours. If there 
is a tendency to collapse, stimulants should be given, and, if necessary, 



TYPHOID FEVER. 



47 



hypodermic injections of ether. Injection of salt solution beneath the 
skin or directly into a vein may revive a failing heart. Turpentine is 
warmly recommended by certain authors. 

Peritonitis. — In a majority of the cases this is an inevitably fatal com- 
plication, though recovery is possible. If the peritonitis be due to perfora- 
tion, the question of laparotomy should be immediately discussed. Orders 
should be issued to the nurse, and in hospitals to the house physicians, to 
watch carefully for the first symptoms of perforation. The recent re- 
sults are most gratifying. Finney (Studies III) has reviewed the whole 
question; of 112 cases 23 recovered. To January 1, 1901) 11 cases have been 
operated upon from my wards with 5 recoveries. The danger of delay is 
illustrated by the following figures: Of 15 cases operated on within twelve 
hours, 4 recovered; of 20 cases operated on between the twelfth and twenty- 
fourth hour, 6 recovered; of 13 cases operated on in the second twenty-four 
hours only 1 recovered. No case is so desperate, unless actually moribund, 
as to be without some hope in the hands of a good surgeon. 

Bone Lesions. — The typhoid periostitis of the ribs or of the tibia does 
not always go on to suppuration, though, as a rule, it requires operation. 
Unless the practitioner is accustomed to do very thorough surgical work, 
he should hand over the patient to a competent surgeon, who will clear 
out the diseased parts with the greatest thoroughness. Recurrence is in- 
evitable unless the operation is complete. 

For the progressive heart-weakness alcohol, strychnine and ether hypo- 
dermically in full doses, digitalis, and the saline infusions may be tried. 

The nervous symptoms of typhoid fever are best treated by hydrother- 
apy. Special advantages of this plan are that the restlessness is allayed, 
the delirium quieted, and sedatives are rarely needed. In the cases which 
set in early with severe headache, meningeal symptoms, and high fever, 
the cold bath, or in private practice the cold pack, should be employed. An 
ice-cap may be placed on the head, and if necessary morphia administered 
hypodermically. For the nocturnal restlessness, so distressing in some 
cases, Dover's powder should be given. As a rule, if a hypnotic is indi- 
cated, it is best to give opium in some form. Pulmonary complications 
should, if severe, receive appropriate treatment. 

Bacilluria. — When bacilli are present, as demonstrated by cultures or 
shown by the microscope, urotropin may be given in ten-grain doses and 
kept up, if necessary, for several weeks. 

In protracted cases very special care should be taken to guard against 
leal-sores. Absolute cleanliness and, careful drying of the parts after an 
evacuation should be enjoined. The patient should be turned from side 
to side and propped with pillows, and the back can then be sponged 
with spirits. On the first appearance of a sore, the water- or air-bed should 
be used. 

(h) The Management of Convalescence— Convalescents from typhoid 
fever frequently cause greater anxiety than patients in the attack. The 
question of food has to be met at once, as the patient acquires a ravenous 
appetite and clamors for a fuller diet. My custom has been not to allow 
solid food until the temperature has been normal for ten days. This is, i 



48 



SPECIFIC INFECTIOUS DISEASES. 



think, a safe rule, leaning perhaps to the side of extreme caution; but, 
after all, with eggs, milk toast, milk puddings, and jellies, the patient can 
take a fairly varied diet. Many leading practitioners allow solid food to a 
patient so soon as he desires it. Peabody gives it on the disappearance of 
the fever; the late Austin Flint was also in favor of giving solid food 
early. I had a lesson in this matter which I have never forgotten. A 
young lad in the Montreal General Hospital, in whose case I was much 
interested, passed through a tolerably sharp attack of typhoid fever. Two 
weeks after the evening temperature had been normal, and only a day or 
two before his intended discharge, he ate several mutton chops, and within 
twenty-four hours was in a state of collapse from perforation. A small 
transverse rent was found at the bottom of an ulcer which was in process 
of healing. It is not easy to say why solid food, particularly meats, should 
disagree, but in so many instances an indiscretion in diet is followed by 
slight fever, the so-called febris carnis, that it is in the best interests of the 
patient to restrict the diet for some time after the fever has fallen. An 
indiscretion in diet may indeed precipitate a relapse. The patient may 
be allowed to sit up for a short time about the end of the first week of 
convalescence, and the period may be prolonged with a gradual return of 
strength. He should move about slowly, and when the weather is favor- 
able should be in the open air as much as possible. He should be guarded 
at this period against all unnecessary excitement. Emotional disturbance 
not infrequently is the cause of recrudescence of the fever. Constipation is 
not uncommon in convalescence and is best treated by enemata. A pro- 
tracted diarrhoea, which is usually due to ulceration in the colon, may 
retard recovery. In such cases the diet should be restricted to milk, and 
the patient should be confined to bed; large doses of bismuth and astrin- 
gent injections will prove useful. The recrudescence of the fever does not 
require special measures. The treatment of the relapse is essentially that 
of the original attack. 

Post-typhoid insanity requires the judicious care of an expert. The 
cases usually recover. The swollen leg after phlebitis is a source of great 
worry. A bandage should be worn during the day or a well-fitting elastic 
stocking. The outlook depends on the completeness with which the col- 
lateral circulation is established. 

The post-typhoid neuritis, a cause of much alarm and distress, usually 
gets well, though it may take months, or even a couple of years, before 
the paralysis disappears. After the subsidence of the acute symptoms 
systematic massage of the paralyzed and atrophic muscles is the most sat- 
isfactory treatment. 

The condition spoken of as the typhoid spine may drag on for months 
and prove very obstinate. The neurotic state has to be treated. Separa- 
tion from solicitous and sympathetic friends, hydrotherapy in the form of 
the wet pack, and the Paquelin cautery are the most efficacious means of 
cure. An encouraging prognosis may be followed by rapid improvement. 



TYPHUS FEVER. 



49 



II. TYPHUS FEVER. 

Definition. — An acute infectious disease of unknown origin, highly 
contagious, characterized by sudden onset, maculated rash, marked nervous 
symptoms, and a cyclical course terminating by crisis, usually about the 
end of the second week. Post-mortem there are no special lesions other 
than those associated with fever. 

The disease is known by the names of hospital fever, spotted fever, jail 
fever, camp fever, and ship fever, and in Germany is called exanthematic 
typhus, in contradistinction to abdominal typhus. 

Etiology. — Typhus fever has been one of the great epidemics of the 
world. Until the middle of the nineteenth century it prevailed extensively 
in all the larger cities of Europe, and at times extended to widespread 
outbreaks. As Hirsch has remarked, " The history of typhus is written 
in those dark pages of the world's story which tell of the grievous visita- 
tions of mankind by war, famine, and misery of every kind." Few coun- 
tries have suffered more than Ireland, particularly between the years 1817 
and 1819 and in 1846. In England the disease has progressively dimin- 
ished in intensity. In 1875 there were 1,499 deaths, in 1895 only 58 deaths. 
In 1897 there were only 3 cases of typhus fever in the London Fever Hos- 
pitals. The last really great epidemic was in the Turko-Eussian War in 
1877- 78. 

The gradual disappearance of typhus fever is one of the great tri- 
umphs of modern medicine. At present the disease lurks in only a few 
centers in Great Britain and on the Continent, and every few years slight 
outbreaks occur in larger cities, and sporadic cases appear from time to time. 
In the United States typhus fever has not prevailed as an extensive epi- 
demic for many years. There were small outbreaks in New York in 1881- 
'82 and in 1892-'93, and in 1883 in Philadelphia. A remarkable feature is 
the occurrence of a few cases at long intervals of time from any other out- 
breaks and at great distances from any known foci of the disease. This 
was one of the points, which led Murchison to the belief that under favor- 
able conditions the disorder might originate spontaneously. But although 
it is sometimes impossible to explain satisfactorily its importation, such 
negative evidence can not be regarded as conclusive. Certainly, the analogy 
of the other infectious diseases is against this view. 

In 1877 there occurred a local outbreak of typhus at the House of 
Eefuge, in Montreal, a city in which the disease had not existed for many 
years. The overcrowding was so great in the basement rooms of the refuge 
that at night there were not more than 88 cubic feet of space to each per- 
son. Eleven individuals were affected. It was not possible to trace the 
source of infection. 

In the spring of 1901 from one house three cases of fever were admitted 
to my wards, which were regarded at first as typhoid fever, but the fea- 
tures were so anomalous that our suspicions were aroused. The rash was 
perfectly characteristic of typhus, the Widal reaction was negative, blood 
cultures were negative, and a post-mortem on one fatal case showed do 
typhoid lesions, and no cultures were obtained from the spleen or the 



50 



SPECIFIC INFECTIOUS DISEASES. 



Mood post-mortem. The other two cases terminated by crisis, so that I 
think there can be no question that the cases were typhus fever. The 
disease has not prevailed in Baltimore for more than a quarter of a cen- 
tury. The patients were Lithuanians, they lived under most unsanitary 
conditions, and were workers at a suburb frequented by a great many for- 
eigners from the eastern parts of Europe. The origin of the outbreak 
could not be traced, nor did any other cases occur. 

Typhus is one of the most highly contagious of febrile affections. In 
epidemics nurses and doctors in attendance upon the sick are almost inva- 
riably attacked. There is no disease which has so many victims in the 
profession. It is stated that in a period of twenty-five years, among 1,230 
physicians attached to institutions in Ireland, 550 succumbed to this dis- 
ease. Casual attendance upon cases in limited epidemics does not appear 
to be very risky, but when the sick are aggregated in wards the poison ap- 
pears concentrated and the danger of infection is much enhanced. Bed- 
ding and clothes retain the poison for a long time. Murchison thought that 
the virus was thrown off from the lungs and from the skin. It attaches 
itself particularly to the clothing and linen and to the furniture of the 
room, and appears to retain its activity for a remarkably long time. To 
catch the disease there apparently must be fairly intimate contact with the 
patient, more particularly contact with a large number of patients. Thus 
in mild outbreaks of only a few cases physicians and nurses are rarely 
affected, while in severe epidemics all in attendance may be attacked in 
succession. 

Bacteriology. — Hlava in 1891 found a streptobacillus in 20 cases. 
Dubieff and Bruhl in 1893 described a diplococcus found in the blood and 
in the organs of fatal cases. The question practically remains open for 
investigation. 

Morbid Anatomy. — The anatomical changes are those which result 
from intense fever. The blood is dark and fluid; the muscles are of a deep 
red color, and often show a granular degeneration, particularly in the 
heart; the liver is enlarged and soft and may have a dull clay-like lustre; 
the kidneys are swollen; there is moderate enlargement of the spleen, and 
a general hyperplasia of the lymph-follicles. Peyer's glands are not ulcer- 
ated. Bronchial catarrh is usually, and hypostatic congestion of the lungs 
often, present. The skin shows the petechial rash. 

Symptoms. — Incubation. — This is placed at about twelve days, but 
it may be less. There may be ill-defined feelings of discomfort. As a rule, 
however, the invasion is abrupt and marked by chills or a single rigor, 
followed by fever. The chills may recur during the first few days, and 
there is headache with pains in the back and legs. There is early pros- 
tration, and the patient is glad to take to his bed at once. The tempera- 
ture is high at first, and may attain its maximum on the second or third 
day. The pulse is full, rapid, and not so frequently dicrotic as in typhoid. 
The tongue is furred and white, and there is an early tendency to dry- 
ness. The face is flushed, the eyes congested, and the expression dull 
and stupid. Vomiting may be a distressing symptom. In severe cases 
mental symptoms are present from the outset, either a mild febrile de- 



TYPHUS FEVER. 



lirium or an excited, active, almost maniacal condition. Bronchial catarrh 
is common. 

Stage of Eruption. — From the third to the fifth day the eruption ap- 
pears first upon the abdomen and upper part of the chest, and then upon 

the extremities and face ; developing so rapidly that in two or three days 
it is all out. There are two elements in the eruption : a subcuticular mot- 
tling, " a fine, irregular, dusky red mottling, as if below the surface of the 
skin some little distance, and seen through a semi-opaque medium " (Bu- 
chanan) ; and distinct papular rose-spots which change to petechiae. In 
some instances the petechial rash comes out with the rose-spots. Collie 
describes the rash as consisting of three parts — rose-colored spots which 
disappear on pressure, dark-red spots which are modified by pressure, and 
petechiae upon which pressure produces no effect. In children the rash at 
first may present a striking resemblance to that of measles, and give as a 
whole a curiously mottled appearance to the skin. The term mulberry rash 
is sometimes applied to it. In mild cases the eruption is slight, but even 
then is largely petechial in character. As the rash is largely heemorrhagic, 
it is permanent and does not disappear after death. Usually the skin is 
dry, so that sudaminal vesicles are not common. It is stated by some 
authors that a distinctive odor is present. During the second week the 
general symptoms are much aggravated. The prostration becomes more 
marked, the delirium more intense, and the fever rises. The patient lies 
on his back with a dull expressionless face, flushed cheeks, injected con- 
junctivae, and contracted pupils. The pulse increases in frequency and is 
feebler ; the face is dusky, and the condition becomes more serious. Ee- 
tention of urine is common. Coma-vigil is frequent, a condition in which 
the patient lies with open eyes, but quite unconscious ; with it there may 
be subsultus tendinum and picking at the bedclothes. The tongue is dry, 
brown, and cracked, and there are sordes on the teeth. Eespiration is 
accelerated, the heart's action becomes more and more enfeebled, and death 
takes place from exhaustion. In favorable cases, about the end of the 
second week occurs the crisis, in which, often after a deep sleep, the pa- 
tient awakes feeling much better and with a clear mind. The tempera- 
ture falls, and although the prostration may be extreme, convalescence is 
rapid and relapse very rare. This abrupt termination by crisis is in strik- 
ing contrast to the mode of termination in typhoid fever. 

Fever. — The temperature rises steadily during the first four or five 
days, and the morning remissions are not marked. The maximum is usu- 
ally attained by the fifth day, when the temperature may be 105°, 106°, or 
107°. In mild cases it seldom rises above 103°. After reaching its maxi- 
mum the fever generally continues with slight morning remissions until 
the twelfth or fourteenth day, when the crisis occurs, during which fcho 
t3mperature may fall below normal within twelve or twenty-four hours. 
Preceding a fatal termination, there is usually a rapid rise in the feve r to 
108° or even 109°. 

The heart may early show signs of weakness. The first sound be- 
comes feeble and almost inaudible, and a systolic murmur at the apex is 



52 



SPECIFIC INFECTIOUS DISEASES. 



not infrequent. Hypostatic congestion of the lungs occurs in all severe 
cases. The brain symptoms are usually more pronounced than in typhoid, 
and the delirium is more constant. A slight leucocytosis is more common 
than in typhoid. 

The urine in typhus shows the usual febrile increase of urea and uric 
acid. The chlorides diminish or disappear. Albumin is present in a large 
proportion of the cases, but nephritis seldom occurs. 

Variations in the course of the disease are naturally common. There 
are malignant cases which rapidly prove fatal within two or three days ; 
the so-called typhus siderans. On the other hand, during epidemics there 
are extremely mild cases in which the fever is slight, the delirium absent, 
and convalescence is established by the tenth day. 

Complications and Sequelae. — Broncho-pneumonia is perhaps the 
most common complication. It may pass on to gangrene. In certain 
epidemics gangrene of the toes, the hands, or the nose, and in children 
noma or cancrum oris, have occurred. Meningitis is rare. Paralyses, 
which are probably due to a post-febrile neuritis, are not very uncom- 
mon. Septic processes, such as parotitis and abscesses in the subcutane- 
ous tissues and in the joints, are occasionally met with. Xephritis is rare. 
Haematemesis may occur. 

Prognosis. — The mortality ranges in different epidemics from 12 to 
20 per cent. It is very slight in the young. Children, who are quite as 
frequently attacked as adults, rarely die. After middle age the mortality 
is high, in some epidemics 50 per cent. Death usually occurs toward the 
close of the second week and is due to the toxaemia. In the third week it 
more commonly results from pneumonia. 

Diagnosis. — During an epidemic there is rarely any doubt, for the 
disease presents distinctive general characters. Isolated cases may be very 
difficult to distinguish from typhoid fever. While in typical instances the 
eruption in the two affections is very different, yet taken alone it may be 
deceptive, since in typhoid fever a roseolous rash may be abundant and 
there may be occasionally a subcuticular mottling and even petechise. 
The difference in the onset, particularly in the temperature, is marked ; 
but cases in which it is important to make an accurate diagnosis are not 
usually seen until the fourth or fifth day. The suddenness of the onset, 
the greater frequency of the chill, and the early prostration are the dis- 
tinctive features in typhus. The brain symptoms too are earlier. It is 
easy to put down on paper elaborate differential distinctions, which are 
practically useless at the bedside. The "Widal reaction and blood cultures 
are important aids, but in sporadic cases the diagnosis is sometimes ex- 
tremely difficult. I have seen Murchison himself in doubt, and more than 
once I have known the diagnosis to be deferred until the sectio cadaveris. 
Severe cerebro-spinal fever may closely simulate typhus at the outset, but 
the diagnosis is usually clear within a few days. Malignant variola also 
has certain features in common with severe typhus, but the greater extent 
of the haemorrhages and the bleeding from the mucous membranes make 
the diagnosis clear within a short time. The rash at first resembles that 



TYPHUS FEVER. 



53 



of measles, but in the latter the eruption is brighter red in color, often 
crescentic or irregular in arrangement, and appears first on the face. 

The frequency with which other diseases are mistaken for typhus is 
shown by the fact that during and following the epidemic of 1881 in New 
York 108 cases were wrongly diagnosed — one eighth of the entire number 
— and sent to the Eiverside Hospital (F. W. Chapin). 

Treatment. — The general management of the disease is like that of 
typhoid fever. Hydrotherapy should be thoroughly and systematically 
employed. Judging from the good results which we have obtained by 
this method in typhoid cases with nervous symptoms much may be ex- 
pected from it. Certain authorities have spoken against it, but it should 
be given a more extended trial. Medicinal antipyretics are even less suit- 
able than in typhoid, as the tendency to heart-weakness is often more 
pronounced. As a rule, the patients require from the outset a supporting 
treatment ; water should be freely given, and alcohol in suitable doses, 
according to the condition of the pulse. 

The bowels may be kept open by mild aperients. The so-called spe- 
cific medication, by sulphocarbolates, the sulphides, carbolic acid, etc., is 
not- commended by those who have had the largest experience. The spe- 
cial nervous symptoms and the pulmonary symptoms should be dealt with 
as in typhoid fever. In epidemics, when the conditions of the climate are 
suitable, the cases are best treated in tents in the open air. 

III. RELAPSING FEVER (Febris recurrens). 

Definition. — A specific infectious disease caused by the spirochaete 
(spirillum) of Obermeier, characterized by a definite febrile paroxysm 
which usually lasts six days and is followed by a remission of about the 
same length of time, then by a second paroxysm, which may be repeated 
three or even four times, whence the name relapsing fever. 

Etiology. — This disease, which has also the names " famine fever " 
and " seven-day fever," has been known since the early part of the eight- 
eenth century, and has from time to time extensively prevailed in Europe 
especially in Ireland. It is common in India, where the conditions for 
its development seem always to be present, and where it has been specially 
studied by Vandyke Carter, of Bombay. It was first seen in this country 
in 1844, when cases were admitted to the Philadelphia Hospital, which are 
described by Meredith Clymer in his work on fevers. Flint saw cases in 
1850-'51. In 1869 it prevailed extensively in epidemic form in New Y^ork 
and Philadelphia ; since when it has not reappeared. 

, The special conditions under which it develops are similar to those of 
typhus fever. Overcrowding and deficient food are the conditions which 
seem to promote the rapid spread of the virus. Neither age, sex, nor sea- 
son seems to have any special influence. It is a contagious disease and 
may be communicated from person to person, but is not so contagious as 
typhus. Murchison thinks it may be transported by fomites. One attack 
does not confer immunity from subsequent attacks. In 1873 Obermeier 



54 



SPECIFIC INFECTIOUS DISEASES. 



described an organism in the blood which is now recognized as the specific 
agent. This spirillum, or more correctly spirochete, is from 3 to 6 times 
the length of the diameter of a red blood-corpuscle, and forms a narrow 
spiral filament which is readily seen moving among the red corpuscles dur- 
ing a paroxysm. They are present in the blood only during the fever. 
Shortly before the crisis and in the intervals they are not found, though 
small glistening bodies, which are stated to be their spores, appear in the 
blood. The disease has been produced in human beings by inoculation with 
blood taken during the paroxysm. It has also been produced in monkeys. 
Bed-bugs may suck out the spirilla, and Tictin reproduced the disease by 
injecting into a healthy monkey blood sucked by a bug from an infected 
monkey. Nothing is yet known with reference to the life history of the 
spirochete. It has not been found in the secretions or excretions. 

Morbid Anatomy. — There are no characteristic anatomical appear- 
ances in relapsing fever. If death takes place during the paroxysm the 
spleen is large and soft, and the liver, kidneys, and heart show cloudy 
swelling. There may be infarcts in the kidneys and spleen. The bone 
marrow has been found in a condition of hyperplasia. Ecchymoses are 
not uncommon. 

Symptoms. — The incubation appears to be short, and in some in- 
stances the attack develops promptly after exposure ; more frequently, 
however, from five to seven days elapse. 

The invasion is abrupt, with chill, fever, and intense pain in the back 
and limbs. In young persons there may be nausea, vomiting, and convul- 
sions. The temperature rises rapidly and may reach 104° on the evening 
of the first day. Sweats are common. The pulse is rapid, ranging from 
110 to 130. There may be delirium if the fever is high. Swelling of the 
spleen can be detected early. Jaundice is common in some epidemics. 
The gastric symptoms may be severe. There are seldom intestinal symp- 
toms. Cough may be present. Occasionally herpes is noted, and there may 
be miliary vesicles and petechias. During the paroxysm the blood inva- 
riably shows the spirochete, and there is usually a leucocytosis (Ouskow). 
After the fever has persisted with severity or even with an increasing in- 
tensity for five or six days the crisis occurs. In the course of a few hours, 
accompanied by profuse sweating, sometimes by diarrhoea, the temperature 
falls to normal or even subnormal, and the period of apyrexia begins. 

The crisis may occur as early as the third day, or it may be delayed to 
the tenth ; it usually comes, however, about the end of the first week. In 
delicate and elderly persons there may be collapse. The convalescence is 
rapid, and in a few days the patient is up and about. Then in a week, 
usually on the fourteenth day, he again has a rigor, or a series of chills ; 
the fever returns and the attack is repeated. A second crisis occurs from 
the twentieth to the twenty-third day, and again the patient recovers 
rapidly. As a rule, the relapse is shorter than the original attack. A 
second and a third may occur, and there are instances on record of even a 
fourth and a fifth. In epidemics there are cases which terminate by crisis 
cn the seventh or eighth day without the occurrence of relapse. In pro- 



RELAPSING FEVER. 



55 



tracted cases the convalescence is very tedious, as the patient is much ex 
hausted. 

Kelapsing fever is not a very fatal disease. Murchison states that the 
mortality is about 4 per cent. In the enfeebled and old, death may occur 
at the height of the first paroxysm. 

Complications are not frequent. In some epidemics nephritis and 
hematuria have occurred. Pneumonia appears to be frequent and may 
interrupt the typical course of the disease. The acute enlargement of the 



1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 




Chart V. — Relapsing Fever (Murchison). 



spleen may end in rupture, and the hamrorrhage from the stomach, which 
has been met with occasionally, is probably associated with this enlarge- 
ment. Post-febrile paralyses may occur. Ophthalmia has followed cer- 
tain epidemics, and may prove a very tedious and serious complication. 
Jaundice has already been mentioned. In pregnant women abortion usu- 
ally takes place. 

Diagnosis. — The onset and general "symptoms may not at first be dis- 
tinctive. At the beginning of an epidemic the cases are usually regarded 
as anomalous typhoid ; but once the typical course is followed in a case 
the diagnosis is clear. The blood examination is distinctive. 

Treatment. — The paroxysm can neither be cut short nor can its 
recurrence be prevented. It might be thought that quinine, with its pow- 
erful action, would certainly meet the indications, but it does not seem to 
have the slightest influence. The disease must be treated like any other 
continued fever by careful nursing, a regular diet, and ordinary hygienic 
measures. Of special symptoms, pains in the back and in the limbs and 
joints demand opium. In enfeebled persons the collapse at the crisis may 
be serious, and stimulants with ammonia and digitalis should be given 
freely. 



4 



56 



SPECIFIC INFECTIOUS DISEASES. 



IV. SMALL-POX {Variola). 

Definition. — An acute infectious disease characterised by an erup- 
tion which passes through the stages of papule, vesicle, pustule, and 
crust. The mucous membranes in contact with the air may also be 
affected. Severe cases may be complicated with cutaneous and visceral 
haemorrhages. 

Etiology. — It has not yet been determined in what country small- 
pox originated. The disease is said to have existed in China many centu- 
ries before Christ. The pesta magna described by Galen (and of which 
Marcus Aurelius died) is believed to be small-pox. In the sixth century 
it prevailed, and subsequently, at the time of the Crusades, became wide- 
spread. It was brought to America by the Spaniards early in the sixteenth 
century. The first accurate account was given by Ehazes, an Arabian 
physician who lived in the ninth century, and whose admirable description 
is available in Greenhill's translation for the Sydenham Society. In the 
seventeenth century a thorough study of the disease was made by the illus- 
trious Sydenham, who still remains one of the most trustworthy authorities 
on the subject. 

Special events in the history of the disease are the introduction of in- 
oculation into Europe, by Lady Mary Wortley Montagu, in 1718, and the 
discovery of vaccination by Jenner, in 1796. 

Small-pox is one of the most virulent of contagious diseases, and per- 
sons exposed, if unprotected by vaccination, are almost invariably attacked. 
There are instances on record of persons insusceptible to the disease. It is 
said that Diemerbroeck, a celebrated Utrecht professor in the seventeenth 
century, was not only himself exempt, but likewise many members of his 
family. One of the nurses in the small-pox department of the Montreal 
General Hospital stated that she had never been successfully vaccinated, 
and she certainly had no mark. Such instances, however, of natural im- 
munity are very rare. An attack may not protect for life. There are un- 
doubted cases of a second, reputed instances, indeed, of a third attack. 

Age. — Small-pox is common at all ages, but is particularly fatal to young 
children. The foetus in utero may be attacked, but only if the mother 
herself is the subject of the disease. The child may be born with the rash 
out or with the scars. More commonly the fcetus is not affected, and 
children born in a small-pox hospital, if vaccinated immediately, may escape 
the disease ; usually, however, they die early. (See Hunter's works, iv, p. 74.) 

Sex. — Males and females are equally affected. 

Race. — Among aboriginal races small-pox is terribly fatal. When the 
disease was first introduced into America the Mexicans died by thousands, 
and the North American Indians have also been frequently decimated by 
this plague. It is stated that the negro is especially susceptible, and the 
mortality is greater — about 42 per cent in the black, against 29 per cent in 
the white (W. M. Welch). 

The contagium develops in the system of the small-pox patient and is 
reproduced in the pustules. It exists in the secretions and excretions, 



SMALL-POX. 



57 



and in the exhalations from the lungs and the skin. The dried scales con- 
stitute by far the most important element, and as a dust-like powder are 
distributed everywhere in the room during convalescence, becoming at- 
tached to clothing and various articles of furniture. The disease is proba- 
bly contagious from a very early stage, though I think it has not yet been 
determined whether the contagion is active before the eruption develops. 
The poison is of unusual tenacity and clings to infected localities. It is 
conveyed by persons who have been in contact with the sick and by fomites. 
During epidemics it is no doubt widely spread in street-cars and public 
conveyances. It must not be forgotten that an unprotected person may 
contract a very virulent form of the disease from the mild varioloid. The 
question of aerial transmission, of great importance in connection with the 
situation of hospitals, can not be regarded as finally settled. Certain facts 
are in its favor, as those reported by Young. Of 36 cases which occurred 
within 500 yards of the Hastings small-pox pavilion, the percentage of 
small-pox attacks to population ranged from 4.2 within the 100-yard circle 
to 0.2 in the 400- to 500-yard circle. 

The disease smoulders here and there in different localities, and when 
conditions are favorable becomes epidemic. There has been lately one of 
the periodical revivals of the disease. According to the Marine Hospital 
Reports, during 1899 there were 11,136 cases with 553 deaths, during 1900 
there were 20,362 cases with 819 deaths, and to May 3, 1901, there were 
22,344 cases with 349 deaths. The disease has been remarkably mild — so 
mild, indeed, that it has often been mistaken for chicken-pox. In Mont- 
real vaccination, to which many of the French Canadians were opposed, 
had been neglected, so that a large unprotected population grew up in the 
city. On February 28, 1885, a Pullman-car conductor, who had travelled 
from Chicago, where the disease had been slightly prevalent, was admitted 
into the Hotel-Dieu, the civic small-pox hospital being at the time closed. 
Isolation was not carried out, and on the 1st of April a servant in the hos- 
pital died of small-pox. Following her decease, with a negligence abso- 
lutely criminal, the authorities of the hospital dismissed all patients pre- 
senting no symptoms of contagion, who could go home. The disease 
spread like fire in dry grass, and within nine months there died in the 
city, of small-pox, 3,164 persons. 

The nature of the contagium of small-pox is still doubtful. Since the 
issue of the third edition of this work in 1898, Roger and Weil have found 
special bodies, which they believe to be parasites, in the pus and blood ; 
Funck has found another protozoon, sporidium vaccinate, and Copeman 
has obtained zooglea masses made up of bodies resembling spores, which 
he has cultivated in collodion capsules, and with them has produced 
typical vaccine pustules in the calf. 

Morbid Anatomy. — A section of a papule as it is passing into the 
vesicular stage shows in the rete mucosum, close to the true skin, an area 
in which the cells are smooth, granular, and do not take the staining fluid . 
This represents a focus of coagulation-necrosis due, according to Weigert, 
to the presence of micrococci. Around this area there is active inllainma- 



58 



SPECIFIC INFECTIOUS DISEASES. 



tory reaction, and in the vesicular stage the rete mucosum presents re- 
ticuli, or spaces, which contain serum, leucocytes, and fibrin filaments. 
The central depression or umbilication corresponds to the area of primary 
necrosis. In the stage of maturation the reticular spaces become filled 
with leucocytes and many of the cells of the rete mucosum become vesicu- 
lar. The papillae of the true skin below the pustule are swollen and infil- 
trated with embryonic cells to a variable degree. If the suppuration ex- 
tends into this layer, scarring inevitably results ; but if it is confined to 
the upper layer, this does not necessarily follow. In the haemorrhagic cases, 
red corpuscles pass out in large numbers from the vessels and occupy the 
vesicular spaces. They infiltrate also the deeper layers of the epidermis in 
the skin adjacent to the papules. Frequently a hair-follicle passes through 
the centre of a papule. 

In the mouth the pustules may be seen upon the tongue and the buccal 
mucosa, and on the palate. The eruption may be abundant also in the 
pharynx and the upper part of the oesophagus. In exceptionally rare cases 
the eruption extends down the oesophagus and even into the stomach. 
Swelling of the Peyer's follicles is not uncommon ; the pustules have been 
seen in the rectum. 

In the larynx the eruption may be associated with a fibrinous exudate 
and sometimes with oedema. Occasionally the inflammation penetrates 
deeply and involves the cartilages. In the trachea and bronchi there may 
be ulcerative erosions, but true pocks, such as are seen on the skin, do not 
occur. There are no special lesions of the lungs, but congestion and bron- 
cho-pneumonia are very common. The liver is sometimes fatty. A diffuse 
hepatitis, associated with intense congestion of the vessels and migration 
of the leucocytes, has been described ; Weigert has noted small areas of 
necrosis. 

There is nothing special in the condition of the blood, and even in the 
most malignant cases there are no microscopic alterations. In the blood- 
drop, however, it will be seen that the corpuscles, instead of forming rou- 
leaux, are aggregated into irregular clumps. An active leucocytosis is 
present. The heart occasionally shows myocardial changes, parenchyma- 
tous and fatty ; endocarditis and pericarditis are uncommon. French 
writers have described an endarteritis of the coronary vessels in connection 
with small-pox. The spleen is markedly enlarged. Apart from the cloudy 
swelling and areas of coagulation-necrosis, lesions of the kidneys are not 
common. Nephritis may occur during convalescence. Chiari has called 
attention to the frequency of orchitis in this disease ; there are scattered 
areas of necrosis with cell infiltration. 

In the haemorrhagic form extravasations are found on the serous and 
mucous surfaces, in the parenchyma of organs, in the connective tissues, 
and about the nerve-sheaths. In one instance I found the entire retro- 
peritoneal tissue infiltrated with a large coagulum, and there were also ex- 
tensive extravasations in the course of the thoracic aorta. Haemorrhages 
in the bone-marrow have also been described by Golgi. There may be 
haemorrhages into the muscles. Ponfick has described the spleen as very 



SMALL-POX. 



59 



firm and hard in hemorrhagic small-pox, and such was the case in seven 
instances which I examined. The liver has been described' as fatty in 
these rapid cases, but in 5 of my 7 cases it was of normal size, dense, and 
firm. In 2 it was large and fatty ; but one man had necrosis of the tibia, 
and the other was a drunkard. The ecchymoses are scattered over the 
meninges of the brain and cord, and in one case there was a clot in the 
right ventricle. In 5 of the cases there were areas of haemorrhagic infarc- 
tion of the lung. In four instances the pelves of the kidney were blocked 
with dark clots, which extended into the calices and down the ureters. 
In one instance the coats of the bladder were uniformly haemorrhagic and 
not a trace of normal tissue could be seen. The extravasations in the 
mucous membrane of the stomach and intestines were numerous and large. 
Peyer's glands were swollen and prominent in four instances. 
Symptoms. — Three forms of small-pox are described : 

1. Variola vera ; (a) Discrete, (b) Confluent. 

2. Variola hemorrhagica; (a) Purpura variolosa or black small-pox; 
(b) Haemorrhagic pustular form, variola haemorrhagica pustulosa. 

3. Varioloid, or small-pox modified by vaccination. 

1. Variola Vera. — The affection may be conveniently described under 
various stages : (a) Incubation. — " From nine to fifteen days ; oftenest 
twelve." I have seen it develop on the eighth day after exposure to in- 
fection, and there are well-authenticated instances in which the stage of 
incubation has been prolonged to twenty days. It is unusual for patients 
to complain of any symptoms in this stage. 

(b) Invasion. — In adults a chill and in children a convulsion are com- 
mon initial symptoms. There may be repeated chills within the first 
twenty-four hours. Intense frontal headache, severe lumbar pains, and 
vomiting , are very constant features. The pains in the back and in the 
limbs are more severe in the initial stage of this than of any other erup- 
tive fever, and their combination with headache and vomiting is so sug- 
gestive that in epidemics precautionary measures may often be taken sev- 
eral days before the eruption decides positively the nature of the disease. 
The temperature rises quickly, and may on the first day be 103° or 104°. 
The pulse is rapid and full, not often dicrotic. In severe cases there may 
be marked delirium, particularly if the fever is high. The patient is rest- 
less and distressed, the face is flushed, and the eyes are bright and clear. 
The skin is usually dry, though occasionally there are profuse sweats. 
One can not judge from these initial symptoms whether a case is likely 
to be discrete or confluent, as the most intense backache and fever may 
precede a very mild attack. 

In this stage of invasion the so-called initial rashes may occur, of which 
two forms can be distinguished — the diffuse, scarlatinal, and the macular 
or measly form; either of which may be associated witli petechia' and oc- 
cupy a variable extent of surface. In some instances they are general, bul 
as a rule they are limited, as pointed out by Simon, either to the Lower 
abdominal areas, to the inner surfaces of the thighs, and to the Lateral 
thoracic region, or to the axillae. Occasionally they are found over the 



60 



SPECIFIC INFECTIOUS DISEASES. 



extensor surfaces, particularly in the neighborhood of the knees and elbows. 
These rashes, usually purpuric, are often associated with an erythematous 
or erysipelatous blush. The scarlatinal rash may come out as early as the 
second day and be as diffuse and vivid as in a true scarlatina. The measly 
rash may also be diffuse and identical in character with that of measles. 
Urticaria is only occasionally seen. It was present once in my Montreal 
cases. Apparently these initial rashes are more abundant in some epidemics 



2 3 4 5 



10 11 12 13 14 15 16 17 18 



104° P.— 40-0° 



102-2" F.— 39 0° 



100-4° F.— 38-0° 



•6° F. — 37 0° 



mamm 

Fir 



IBUMH 



vara 



fflnmuHHsmim 



1 



VIHHriH«BH0BI 
kllfflBlMNI 



■SSShSSSSh 



wm 

warn warn 
IBHHHHnll 




Initial Fever Eruption. 

Chart VI. 



/ Suppurative Fever. 
-True small-pox (Strumpell). 



than in others ; thus they were certainly more numerous in the Montreal 
epidemics between 1870 and 1875 than they were in the more extensive 
epidemic in 1885. They occur in from 10 to 16 per cent of cases. In the 
cases under my care in the small-pox department at the Montreal General 
Hospital the percentage was 13.* As will be subsequently mentioned these 
initial rashes have considerable diagnostic value. 

(c) Eruption. — (1) In the discrete form, usually on the fourth day, 
small red spots appear on the forehead, particularly at the junction with 
the hair, and on the wrists. Within the first twenty-four hours from their 
appearance they occur on other parts of the face and on the extremities, 
and a* few are seen on the trunk. As the rash comes out the temperature 
falls, the general symptoms subside, and the patient feels comfortable. On 
the fifth or sixth day the papules change into vesicles with clear summits. 
Each one is elevated, circular, and presents a little depression in the centre, 
the so-called umbilication. About the eighth day the vesicles change iriB 
pustules, the umbilication disappears, the flat top assumes a globular form 
and becomes grayish yellow in color, owing to the contained pus. There 
is an areola of injection about the pustules and the skin between them is 
swollen. This maturation first takes place on the face, and follows the 
order of the appearance of the eruption. The temperature now rises — 
secondary fever — and the general symptoms return. The swelling about 
the pustules is attended with a good deal of tension and pain in the face ; 



* The Initial Rashes of Small-pox. Canada Medical and Surgical Journal, 1875. 



1 



SMALL-POX. 61 

the eyelids become swollen and closed. There is a well-marked leucocyto- 
sis in the stage of suppuration. In the discrete form the temperature of 
maturation does not usually remain high for more than twenty-four or 
twenty-six hours, so that on the tenth or eleventh day the fever disappears 
and the stage of convalescence begins. The pustules rapidly dry, first on 
the face and then on the other parts, and by the fourteenth or fifteenth 
day desquamation may be far advanced on the face. There may be in 
addition vesicles in the mouth, pharynx, and larynx, causing soreness and 
swelling in these parts, with loss of voice. Whether pitting takes place 
depends a good deal upon the severity of the disease. In a majority of 
cases Sydenham's statement holds good, that " it is very rarely the case that 
the distinct small-pox leaves its mark." 

(2) The Confluent Form. — With the same initial symptoms, though 
usually of greater severity, the rash appears on the fourth, or, according to 
Sydenham, on the third day. The more the eruption shows itself before 
the fourth day, the more sure it is to become confluent (Sydenham). The 
papules at first may be isolated and it is only later in the stage of matu- 
ration that the eruption is confluent. But in severer cases the skin is 
swollen and hypersemic and the papules are very close together. On the 
feet and hands, too, the papules are thickly set ; more scattered on the 
limbs; and quite discrete on the trunk. With the appearance of the 
eruption the symptoms subside and the fever remits, but not to the same 
extent as in the discrete form. Occasionally the temperature falls to nor- 
mal and the patient may be very comfortable. Then, usually on the eighth 
day, the fever again rises, the vesicles begin to change to pustules, the 
hyperemia about them becomes intense, the swelling of the face and 
hands increases, and by the tenth day the pustules have fully maturated, 
many of them have coalesced, and the entire skin of the head and extremi- 
ties is a superficial abscess. The fever rises to 103° or 104°, the pulse is 
from 110 to 120, and there is often delirium. As pointed out by Syden- 
ham, salivation in adults and diarrhoea in children are common symptoms 
of this stage. There is usually much thirst. The eruption may also be 
present in the mouth, and usually the pharynx and larynx are involved and 
the voice is husky. Great swelling of the cervical lymphatic glands occurs. 
At this stage the patient presents a terrible picture, unequalled in any 
other disease ; one which fully justifies the horror and fright with which 
small-pox is associated in the public mind. Even when the rash is con- 
fluent on the face, hands, and feet, the pustules remain discrete on the 
trunk. The danger, as pointed out by Sydenham, is in proportion to the 
number upon the face. " If upon the face they are as thick as sand it is 
no advantage to have them few and far between on the rest of the body." 
In fatal cases, by the tenth or eleventh day the pulse gets feebler and more 
rapid, the delirium is marked, there is subsultus, sometimes diarrhoea, and 
with these symptoms the patient dies. In other instances between the 
eighth and eleventh day hemorrhagic symptoms develop. When recov- 
ery takes place, the patient enters on the eleventh or twelfth day bhe 
period of — 



62 



SPECIFIC INFECTIOUS DISEASES. 



(d) Desiccation. — The pustules break and the pus exudes and forms 
crusts. Throughout the third week the desiccation proceeds and in cases 
of moderate severity the secondary fever subsides ; but in others it may 
persist until the fourth week. The crusts in confluent small-pox adhere 
for a long time and the process of scarring may take three or four weeks. 
The crusts on the face fall off, but the tough epidermis of the hands and 
feet may be shed entire. We had in the small-pox department of the 
Montreal General Hospital several moulds in epithelium of the hands and 
feet. 

2. Hemorrhagic small-pox occurs in two forms. In one the special 
symptoms appear early and death follows in from two to six days. This 
is the so-called petechial or black small-pox— purpura variolosa. In the 
other form the case progresses as one of ordinary variola, and it is not 
until the vesicular or pustular stage that haemorrhage takes place into the 
pocks or from the mucous membranes. This is sometimes called variola 
Immorrhagica pustulosa. 

Haemorrhagic small-pox is more common in some epidemics than in 
others. It is less frequent in children than in adults. Of 27 cases ad- 
mitted to the small-pox department of the Montreal General Hospital 
there were 3 under ten years, 4 between fifteen and twenty, 9 between 
twenty and twenty-five, 7 between twenty-five and thirty-five, 3 between 
thirty-five and forty-five, and 1 above fifty. Young and vigorous persons 
seem more liable to this form. Several of my cases were above the aver- 
age in muscular development. Men are more frequently affected than 
women ; thus in my list there were 21 males and only 6 females. The 
influence of vaccination is shown in the fact that of the cases 14 were un- 
vaccinated, while not one of the 13 who had scars had been revaccinated. 

The clinical features of the forms of haemorrhagic small-pox are some- 
what different. 

In purpura variolosa the illness starts with the usual symptoms, but 
with more intense constitutional disturbance. On the evening of the 
second or on the third day there is a diffuse hyperaemic rash, particularly 
in the groins, with small punctiform haemorrhages. The rash extends, 
becomes more distinctly haemorrhagic, and the spots increase in size. 
Ecchymoses appear on the conjunctivae, and as early as the third day 
there may be haemorrhages from the mucous membranes. Death may 
take place before the rash appears. This is truly a terrible affection and 
well developed cases present a frightful appearance. The skin may have 
a uniformly purplish hue and the unfortunate victim may even look plum- 
colored. The face is swollen and large conjunctival haemorrhages with 
the deeply sunken corneae give a ghastly appearance to the features. The 
mind may remain clear to the end. Death occurs from the third to the 
sixth day ; thus in thirteen of my cases it took place between these dates. 
The earliest death was on the third day and there were no traces of 
papules. There may be no mucous haemorrhages ; thus in one case of a 
most virulent character death occurred without bleeding early on the fourth 
day. Haematuria is perhaps most common, next haematemesis, and melaena 



SMALL-POX. 63 

was noticed in a third of the cases. Metrorrhagia was present in one only 
of the six females on my list. Haemoptysis occurred in five cases. The 
pulse in this form of small-pox is rapid and often hard and small. The 
respirations are greatly increased in frequency and out of all proportion to 
the intensity of the fever. In the case' of a negro, whose respirations 
the morning after admission were 32 and temperature 101°, after examin- 
ing the lungs and finding nothing to account for the relatively rapid 
breathing, my suspicions were aroused, and even on the dark skin I was 
able on careful inspection to detect haemorrhages in and about the papules. 

In variola pustulosa limmorrliagica the disease progresses as an ordinary 
case of severe variola, and the haemorrhages do not develop until the vesicu- 
lar or pustular stage. The earlier the haemorrhage the greater is the dan- 
ger. There are undoubtedly instances of recovery when the bleeding has 
taken place at the stage of maturation. Bleeding from the mucous mem- 
branes is also common in this form, and the great majority of the cases 
prove fatal, usually on the seventh, eighth, or ninth day. 

There is a form of haemorrhagic small-pox in which bleeding takes 
place into the pocks in the vesicular stage and is followed by a rapid 
abortion of the rash and a speedy recovery. Six instances of this kind 
came under my observation.* 

Variations in the Virulence of Epidemics. — Sydenham states that 
" small-pox also has its peculiar kinds, which take one form during one 
series of years, and another during another." 0. J. Porter calls attention 
to the fact that John Mason Good, in his Study of Medicine, describes 
a number of very mild outbreaks, some of which were mistaken for 
chicken-pox. Xot only does what Sydenham calls the epidemic consti- 
tution vary greatly, but one sometimes sees the most extraordinary varia- 
tions in the intensity of the disease in members of a family all exposed 
to the same infection. 

3. Varioloid. — This term is applied to the modified form of small-pox 
which affects persons who have been vaccinated. It may set in with 
abruptness and severity, the temperature reaching 103°. More commonly 
it is in every respect milder in its initial symptoms, though the headache 
and backache may be very distressing. The papules appear on the even- 
ing of the third or on the fourth day. They are few in number and may 
be confined to the face and hands. The fever drops at once and the pa- 
tient feels perfectly comfortable. The vesiculation and maturation of the 
pocks take place rapidly and there is no secondary fever. There is rarely 
any scarring. As a rule, when small-pox attacks a person who has been 
vaccinated within five or six years the disease is mild, but there are in- 
stances in which it is very severe, and it may even prove fatal. 

There are several forms of rash; thus in what has been known as horn- 
pox, crystalline pox, and wart-pox the papules come out in numbers on the 
third or fourth day, and by the fifth or sixth day have dried to a hard, 
horny consistence. 



* Clinical Notes on Small-pox. Montreal, L876. 



64 



SPECIFIC INFECTIOUS DISEASES. 



Writers describe a variola sine eruptione, which is met with during epi- 
demics in young persons who have been well vaccinated, and who present 
simply the initial symptoms of fever, headache, and backache. In a some- 
what extensive experience in Montreal I do not remember to have met with 
an instance of this kind, or indeed to have heard of one. 

We do not now see the modified form of small-pox, resulting from in- 
oculation, in which by the seventh or eighth day a pustule forms at the 
seat of inoculation ; after this general fever sets in, and with it, about the 
eleventh day, appears a general eruption, usually limited in degree. 

Complications. — Considering the severity of many of the cases and 
the general character of the disease, associated with multiple foci of sup- 
puration, the complications in small-pox are remarkably few. 

Laryngitis is serious in three ways : it may produce a fatal oedema of 
the glottis ; it is liable to extend and involve the cartilages, producing 
necrosis ; and by diminishing the sensibility of the larynx, it may allow 
irritating particles to reach the lower air-passages, where they excite 
bronchitis or broncho-pneumonia. 

Broncho-pneumonia is indeed one of the most common complications, 
and is almost invariably present in fatal cases. Lobar pneumonia is rare. 
Pleurisy is common in some epidemics. 

The cardiac complications are also rare. In the height of the fever a 
systolic murmur at the apex is not uncommon ; but endocarditis, either 
simple or malignant, is rarely met with. Pericarditis too is very uncom- 
mon. Myocarditis seems to be more frequent, and may be associated with 
endarteritis of the coronary vessels. 

Of complications in the digestive system, parotitis is rare. In severe 
cases there is extensive pseudo-diphtheritic angina. Vomiting, which is 
so marked a symptom in the early stage, is rarely persistent. Diarrhoea 
is not uncommon, as noted by Sydenham, and is very constantly present 
in children. 

Albuminuria is frequent, but true nephritis is rare. Inflammation of 
the testes and of the ovaries may occur. 

Among the most interesting and serious complications are those per- 
taining to the nervous system. In children convulsions are common. In 
adults the delirium of the early stage may persist and become violent, and 
finally subside into a fatal coma. Post-febrile insanity is occasionally met 
with during convalescence, and very rarely epilepsy. Many of the old 
writers spoke of paraplegia in connection with the intense backache of 
the early stage, but it is probably associated with the severe agonising 
lumbar and crural pains and is not a true paraplegia. It must be distin- 
guished from the form occurring in convalescence, which may be due to 
peripheral neuritis or to a diffuse myelitis (Westphal). The neuritis may, 
as in diphtheria, involve the pharynx alone, or it may be multiple. Of this 
nature, in all probability, is the so-called pseudo-tabes, or ataxie variolique. 
Hemiplegia and aphasia have been met with in a few instances, the result 
of encephalitis. 

Among the most constant and troublesome complications of small-pox 



SMALL-POX. 



65 



are those involving the skin. During convalescence boils are very fre- 
quent and may be severe. Acne and ecthyma are also met with. Local 
gangrene in various parts may occur. 

Arthritis may develop, usually in the period of desquamation, and may 
pass on to suppuration. Acute necrosis of the bone is sometimes met 
with. 

A remarkable secondary eruption (recurrent small-pox) occasionally 
occurs after desquamation. 

Special Senses. — The eye affections which were formerly so common 
and serious are not now so frequent, owing to the care which is given to 
keeping the conjunctivas clean. A catarrhal and purulent conjunctivitis 
is common in severe cases. The secretions cause adhesions of the eyelids, 
and unless great care is taken a diffuse keratitis is excited, which may go 
on to ulceration and perforation. Iritis is not very uncommon. Otitis 
media is an occasional complication, and usually results from an extension 
of the disease through the Eustachian tubes. 

Prognosis. — In unprotected persons small-pox is a very fatal disease. 
In different epidemics the death-rate is from 25 to 35 per cent. In Wil- 
liam M. Welch's report from the Municipal Hospital, Philadelphia, of 
2,831 cases of variola, 1,534 — i. e., 54.18 per cent — died, while of 2,169 
cases of varioloid only 28 — i. e., 1.29 per cent — died. Purpura variolosa is 
invariably fatal, and a majority of those attacked with the severer confluent 
forms die. In young children it is particularly fatal. In the Montreal 
epidemic of 1885 and 1886, of 3,164 deaths there were 2,717 under ten 
years. The intemperate and debilitated succumb more readily to the dis- 
ease. As Sydenham observed, the danger is directly proportionate to the 
intensity of the disease on the face and hands. " When the fever increases 
after the appearance of the pustules, it is a bad sign ; but, if it is lessened 
on their appearance, that is a good sign " (Ehazes). Very high fever, with 
delirium and subsultus, are symptoms of ill omen. The disease is particu- 
larly fatal in pregnant women and abortion usually takes place. It is not, 
however, uniformly so, and I have twice known severe cases to recover 
after miscarriage. Moreover, abortion is not inevitable. Very severe 
pharyngitis and laryngitis are fatal complications. 

Death results in the early stage from the action of the poison upon the 
nervous system. In the later stages it usually occurs about the eleventh 
or twelfth day, at the height of the eruption. In children, and occasion- 
ally in adults, the laryngeal and pulmonary complications prove fatal. 

Diagnosis. — During an epidemic the initial chill, the headache 1 and 
backache, and the vomiting at once put the physician on his guard. 

The initial rashes may lead to error. The scarlatina] rash has rarely 
the extent and never the persistence of the rash in true scarlet fever. I 
have known the rash of measles to be mistaken for the initial rash of 
small-pox. The general condition of the patient, and the presence of 
coryza and conjunctivitis and Koplik's sign, may be better guides I nan the 
rash itself. 

Malignant hemorrhagic small-pox may prove fatal before the charac- 



66 



SPECIFIC INFECTIOUS DISEASES. 



teristic rash appears. In 1 of 27 cases of hemorrhagic small-pox, in which 
death occurred on the third day, inspection failed to show the papules. 
In 3 cases dying on the fourth day the characteristic papular rash was 
noticed. It may be difficult or impossible to recognize latent haemorrhagic 
small-pox from hcemorrhagic scarlet fever or hcemorrhagic measles, though 
in the latter there is rarely so constant involvement of the mucous mem- 
branes. Naturally enough, as they are allied affections, varicella is the 
disease which most frequently leads to error. Particularly has this been 
the case in the mild epidemic which has prevailed throughout the country 
during the past three years. A negro patient was admitted to my wards 
on the fourth day of the disease. Small-pox was not prevalent at the time, 
and the case was regarded as one of varicella. Within fourteen days eight 
cases appeared, several of exceeding mildness, but our mistake was forcibly 
brought home to us by the occurrence, in a man who had been exposed in 
the ward, of a case of confluent small-pox of great severity. The following 
points are to be borne in mind : first, the experience of the past few years 
has shown that very mild epidemics of true small-pox may occur ; secondly, 
any large number of cases of a contagious disease with a pustular eruption 
occurring in adults is strongly in favor of small-pox. The characters of 
the rash are of less value. Its abundance on the trunk in varicella is 
important. At the outset the papules have rarely the shotty, hard feel of 
small-pox. The vesicles are more superficial, the infiltrated areola is not 
so intense nor so constant, and as a rule the pocks may be seen in the same 
patient in all stages of development. The longer period of invasion, the 
prodromal rashes, the greater intensity of the onset, are also important 
points in small-pox. But, as I have said, there are mild epidemics in 
which it must be confessed that the recognition of the nature of the out- 
break is sometimes only confirmed by the appearance of a genuine case of 
the confluent or of the hsemorrhagic form. 

The disease may be mistaken for cerebrospinal fever, in which purpuric 
symptoms are not uncommon. A four-year-old child was taken suddenly 
ill with fever, pains in the back and head, and on the second or third day 
petechise appeared on the skin. There were retraction of the head, and 
marked rigidity of the limbs. The haemorrhages became more abundant ;. 
and finally haematemesis occurred and the child died on the sixth day. At 
the post mortem there were no lesions of cerebro-spinal fever, and in the 
deeply hsemorrhagic skin the papules could be readily seen. The post- 
mortem diagnosis of small-pox was unhappily confirmed by the mother 
taking the disease and dying of it. 

Pustular SypMlides. — A very copious pustular rash in syphilis may 
resemble variola, particularly if accompanied by fever, but the history and 
the distribution, particularly the slight amount on the face, leaves no 
question as to the diagnosis. 

Pustular glanders has been mistaken for small-pox. In a remarkable 
instance of the kind in Montreal there was a widespread pustular erup- 
tion, which we thought at first was small-pox, but the subsequent course 
and the fact that there was glanders among the horses in the stable led 



SMALL-POX. 



67 



to the correct diagnosis. The eruption resembled exactly that given in 
Eayer's plate. 

Impetigo contagiosa is stated to have been mistaken for variola. 

Blood Examination. — There is always a leucocytosis, and several French 
observers have of late claimed that there is a characteristic leucocytic 
index in the disease. The large mononuclears are increased to from 4 to 
10 per cent, the myelocytes to from 2 to 10 per cent. The nucleated reds 
are also seen, especially in the hemorrhagic form. 

Treatment. — In the interests of public health cases of small-pox 
should invariably be removed to special hospitals, since it is impossible 
to take the proper precautions in private houses. The general hygienic 
arrangements of the room should be suitable for an infectious disease. 
All unnecessary furniture and the curtains and carpets should be removed. 
The greatest care should be taken to keep the patient thoroughly clean, 
and the linen should be frequently changed. The bedclothing should be 
light. It is curious that the old-fashioned notion, which Sydenham tried 
so hard to combat, that small-pox patients should be kept hot and warm, 
still prevails ; and I have frequently had to protest against the patient 
being, as Sydenham expresses it, stifled in his bed. Special care should 
be taken to sterilize thoroughly everything that has been in contact with 
the patient. 

In the early stage the pain in the back and limbs requires opium, 
which, as advised by Sydenham, may be freely given. The diet should 
consist of milk and broths, and of " all articles which give no trouble to 
digestion." Cold drinks may be freely given. Barley-water and the 
Scotch borse (oatmeal and water) are both nutritious and palatable. 
After the preliminary vomiting, which is often very hard to check by 
ordinary measures, the appetite is usually good, and, if the throat is not 
very sore, patients with the confluent form take nourishment well. In 
the hemorrhagic cases the vomiting is usually aggravated and persistent. 

The fever when high must be kept within limits, and it is best to use 
either cold sponging or the cold bath. When the pyrexia is combined 
with delirium and subsultus, the patient should be placed in a bath at 70°, 
and this repeated as often as every three hours if the temperature rises 
above 103°. When it is not practicable to give the cold bath, the cold 
pack can be employed. These measures are much preferable in small-pox 
to the administration of medicinal antipyretics. 

The treatment of the eruption has naturally engaged the special atten- 
tion of the profession. The question of the preventing of pitting, so much 
discussed, is really not in the hands of the physician. It depends entirely 
upon the depth to which the individual pustules reach. After trying all 
sorts of remedies, such as puncturing the pustules with nitrate of silver, or 
treating them with iodine and various ointments, I came to Sydenham's 
conclusion that in guarding the face against being disfigured by the sears 
"the only effect of oils, liniments, and the like, was to make the white 
scurfs slower in coming off." There is, I believe, something in protecting 
the ripening papules from the light, and the constant application on the 



68 



SPECIFIC INFECTIOUS DISEASES. 



face and hands of lint soaked in cold water, to which antiseptics such as 
carbolic acid or bichloride may be added, is perhaps the most suitable 
local treatment. It is very pleasant to the patient, and for the face it is 
well to make a mask of lint, which can then be covered with oiled silk. 
When the crusts begin to form, the chief point is to keep them thoroughly 
moist, which may be done with oil or glycerin. This prevents the desicca- 
tion and diffusion of the flakes of epidermis. Vaseline is particularly use- 
ful, and at this stage may be freely used upon the face. It frequently 
relieves the itching also. For the odor, which is sometimes so character- 
istic and disagreeable, the dilute carbolic solutions are probably best. If 
the eruption is abundant on the scalp, the hair should be cut short to 
prevent matting and decomposition of the crusts. During convalescence 
frequent bathing is advisable, because it helps to soften the crusts. The 
care of the eyes is particularly important. The lids should be thoroughly 
cleansed three or four times a day, and the conjunctivae washed with some 
antiseptic solution. In the confluent cases, when the eyelids are much 
swollen and the lids glued together, it is only by watchfulness that kerati- 
tis can be prevented. The mouth and throat should be kept clean, and if 
crusts form in the nose they should be softened by frequent injections. 
Ice can be given, and is very grateful when there is much angina. In 
moderate cases, so soon as the fever subsides the patient should be allowed 
to get up, a practice which Sydenham warmly urged. The diarrhoea, when 
severe, should be checked with paregoric. When the pulse becomes feeble 
and rapid, stimulants may be freely given. The delirium is occasionally 
maniacal and may require chloroform, but for the nervous symptoms the 
bath or cold pack is the best. For the severe haemorrhages of the malig- 
nant cases nothing can be done, and it is only cruel to drench the unfortu- 
nate patient with iron, ergot, and other drugs. Symptoms of obstruction 
in the larynx, usually from oedema, may call for tracheotomy. In the late 
stages of the disease, should the patient be extremely debilitated and the 
subject of abscesses and bed-sores, he may be placed on a water-bed or 
treated by the continuous warm bath. During convalescence the patient 
should bathe daily and use carbolic soap freely in order to get rid of the 
crusts and scabs. He should not be considered without danger to others 
until the skin is perfectly smooth and clean, and free from any trace of 
scabs. I have not mentioned any of the so-called specifics or the inter- 
nal antiseptics, which have been advised in such numbers ; so far as I 
know, those who have had the widest experience with the disease do 
not favor their use. 



V. VACCINIA {Cow-pox)— VACCINATION. 

Definition. — An eruptive disease of the cow, the virus of which, inocu- 
lated into man (vaccination), produces a local pock with constitutional 
disturbance, which affords protection, more or less permanent, against 
small-pox. 

The vaccine is got either directly from the calf — animal lymph — in 



VACCINIA— VACCINATION. 



69 



which the disease is propagated at regular stations, or is obtained from 
persons vaccinated (humanized lymph). 

History. — For centuries it had been a popular belief among farmer 
folk that cow-pox protected against small-pox. It is said that the notorious 
Duchess of Cleveland, replying to some joker who suggested that she would 
lose her occupation if she was disfigured with small-pox, said that she was 
not afraid of the disease, as she had had cow-pox. Jesty, a Dorsetshire 
farmer, had had cow-pox, and in 1774 vaccinated successfully his wife and 
two sons. Plett, in Holstein, in 1791, also successfully vaccinated three 
children. When Jenner was a student at Sodbury, a young girl, who came 
for advice, when small-pox was mentioned, exclaimed, " I can not take that 
disease, for I have had cow-pox/' J enner subsequently mentioned the sub- 
ject to Hunter, who in reply gave the famous piece of advice: "Do not 
think, but try; be patient, be accurate/' As early as 1780 the idea of the 
protective power of vaccination was firmly impressed on Jenner's mind. 
The problem which occupied his attention for many years was brought to 
a practical issue when, on May 14, 1796, he took matter from the hand of 
a dairy-maid, Sarah Nelmes, who had cow-pox, and inoculated a boy named 
James Phipps, aged eight years. On July 1st matter was taken from a 
small-pox pustule, and inserted into the boy, but no disease followed. In 
1798 appeared An Inquiry into the Causes and Effects of the Variola 
Vaccinae, a Disease discovered in some of the Western Counties of England, 
particularly Gloucestershire, and known by the Name of Cow-pox (pp. iv, 
75, four plates, 4to. London, 1798). From this time on vaccination spread 
rapidly throughout the civilized world. 

In the United States vaccination was introduced by Benjamin Water- 
house, Professor of Physic at Harvard, who on July 8, 1800, vaccinated 
seven of his children. President Jefferson was mainly instrumental in 
spreading the practice in the Southern States, and John Eedman Coxe 
introduced it into Philadelphia. 

The literature of vaccination has been greatly enriched by the pub- 
lications in connection with the Jenner centenary. The centenary number 
of the British Medical Journal is particularly valuable. The report of the 
Eoyal Commission on vaccination, the exhaustive article in Allbutt's System 
by T. D. Ackland and Copeman, and Cory's recent monograph on the 
subject afford a large body of material. To the public health officials, who 
wish for distribution in handy shape Facts about Small-pox and Vaccina- 
tion, the leaflets issued by the British Medical Association (British Medical 
Journal, 1898, vol. i, p. 632) will be of the greatest value. 

Nature of Vaccinia. — Is cow-pox a separate independent disease, 
or is it only small-pox modified by passing through the cow? In spite of 
a host of observations, this question is not yet settled, as may be seen in 
the diametrically opposed views expressed by Copeman in Allbutt's System 
and by Brouardel in the Twentieth Century Practice. The experiments 
may be divided into two groups. First, those in which the inoculation of 
the small-pox matter in the heifer produced pocks corresponding in nil 
respects to the vaccine vesicles. Lymph from the first calf inoculated into 
a second or third produced the characteristic lesions of cow-pox, ami from 



TO 



SPECIFIC INFECTIOUS DISEASES. 



the first, second, or third animal lymph used to vaccinate a child produced 
a typical localized vaccine vesicle without any of the generalized features 
of small-pox. The experiments of Ceely, of Babcock, and many other more 
recent workers seem to leave no question whatever that typical vaccinia 
may be produced in the calf by the inoculation of variolous matter. A 
great deal of the vaccine material at one time in use in England was ob- 
tained in this way. Secondly, against this is urged Chauveau's Lyons 
experiments. Seventeen young animals were inoculated with the virus of 
small-pox. Small reddish papules occurred which disappeared rapidly, but 
the animals did not acquire cow-pox. Fifteen of the seventeen animals 
were also vaccinated. Of these only one showed a typical cow-pox erup- 
tion. To determine the nature of the original papules one was excised and 
inoculated into a non-vaccinated child, which developed as a result general- 
ized confluent small-pox. A second child inoculated from the primary 
pustule of the first child developed discrete small-pox. The French still 
hold to the Lyons experiments as demonstrating the duality of the dis- 
eases. 

The weight of evidence favors the view that cow-pox and horse-pox 
are variola modified by transmission; or, as has been suggested, " small-pox 
and vaccinia are both of them descended from a common stock — from an 
ancestor, for instance — which resembled vaccinia far more than it resem- 
bled small-pox" (Copeman). 

Bacteriology of Vaccinia. — This, too, is still unsettled. Quist, Martin, 
and Ernst have described various micrococci. Klein and Copeman have 
independently found a bacillus, while Pfeiffer and Puffer have met with 
bodies believed to be of the nature of psorosperms. Walter Reed has also 
met with peculiar amoeboid bodies in the blood. 

Normal Vaccination. — Period of Incubation. — At first there may 
be a little irritation at the site of inoculation, which subsides. Period of 
Eruption. — On the third day, as a rule, a papule is seen surrounded by a 
reddish zone. This gradually increases, and on the fifth or sixth day shows 
a definite vesicle, the margins of which are raised while the centre is de- 
pressed. By the eighth day the vesicle has attained its maximum size. It 
is round and distended with a limpid fluid, the margin hard and prominent, 
and the umbilication is more distinct. By the tenth day the vesicle is still 
large and is surrounded by an extensive areola. The contents have now be- 
come purulent. The skin is also swollen, indurated, and often painful. On 
the eleventh or twelfth day the hyperemia diminishes, the lymph becomes 
more opaque and begins to dry. By the end of the second week the vesicle 
is converted into a brownish scab, which gradually becomes dry and hard, 
and in about a week (that is, about the twenty-first or twenty-fifth day from 
the vaccination) separates and leaves a circular pitted scar. If the points 
of inoculation have been close together, the vesicles fuse and may form 
a large combined vesicle. Constitutional symptoms of a more or less 
marked degree follow the vaccination. Usually on the third or fourth day 
the temperature rises, and may persist, increasing until the eighth or ninth 
day. There is a marked leucocytosis. In children it is common to have 
with the fever restlessness, particularly at night, and irritability: but as a 

0 



VACCINIA— VACCINATION. 



Tl 



rule these symptoms are trivial. If the inoculation is made on the arm, 
the axillary glands become large and sore; if on the leg, the inguinal 
glands. The duration of the immunity is extremely variable, differing 
in different individuals. In some instances it is permanent, but a majority 
of persons within ten or twelve years again become susceptible. 

Revaccination should be performed between the tenth and fifteenth 
year, and whenever small-pox is epidemic. The susceptibility to revac- 
cination is curiously variable, and when small-pox is prevalent it is not well, 
if unsuccessful, to be content with a single attempt. The vesicle in re- 
vaccination is usually smaller, has less induration and hyperemia, and the 
resulting scar is less perfect. Particular care should be taken to watch 
the vesicle of revaccination, as it not infrequently happens that a spurious 
pock is formed, which reaches its height early and dries to a scab by the 
eighth or ninth day. The constitutional symptoms in revaccination are 
sometimes quite severe. 

Irregular Vaccination. — (a) Local Variations. — We occasionally 
meet with instances in which the vesicle develops rapidly with much itch- 
ing, has not the characteristic flattened appearance, the lymph early be- 
comes opaque, and the crust forms by the seventh or eighth day. The 
evolution of the pocks may be abnormally slow. In such cases the operation 
should again be performed with fresh lymph. The contents of the vesi- 
cles may be watery and bloody. In the involution the bruising or irrita- 
tion of the pocks may lead to ulceration and inflammation. A very rare 
event is the recurrence of the pock in the same place. Sutton reports four 
such recurrences within six months. 

(b) Generalized Vaccinia. — It is not uncommon to see vesicles in the 
vicinity of the primary sore. Less common is a true generalized pustular 
rash, developing in different parts of the body, often beginning about the 
wrists and on the back. The secondary pocks may continue to make their 
appearance for five or six weeks after vaccination. In children the disease 
may prove fatal. They may be most abundant on the vaccinated limb, 
and develop usually about the eighth to the tenth day. 

(c) Complications. — In unhealthy subjects, or as a result of uncleanli- 
ness, or sometimes injury, the vesicles inflame and deep excavated ulcers 
result. Sloughing and deep cellulitis may follow. In debilitated children 
there may be with this a purpuric rash. Acland thus arranges the dates at 
which the possible eruptions and complications may be looked for: 

1. During the first three days: Erythema; urticaria; vesicular and 
bullous eruptions; invaccinated erysipelas. 

2. After the third day and until the pock reaches maturity: Urticaria; 
lichen urticatus, erythema multiforme; accidental erysipelas. 

3. About the end of the first week: Generalized vaccinia; impetigo; vac- 
cinal ulceration; glandular abscess; septic infections; gangrene. 

4. After the involution of the pocks: Invaccinated diseases — for exam- 
ple, syphilis. 

(d) Transmission of Disease by Vaccination . — Syphilis has undoubtedly 
been transmitted by vaccination, but such instances arc very pare. A 
number of the cases of alleged vaccino-syphilis must he thrown out. 

5 



72 



SPECIFIC INFECTIOUS DISEASES. 



question has now become really of minor importance since the widespread 
use of animal lymph. Dr. Cory's sad experiment may here be referred to. 
He vaccinated himself four times from syphilitic children. The first vac- 
cination followed, but no syphilis. Two other attempts (negative) were 
made. The fourth time he was vaccinated from a child the subject of 
congenital syphilis. The lymph was taken from the child's arm with care, 
avoiding any contamination with blood. At two of the points of insertion 
red papules appeared on the twenty-first day. On the thirty-eighth day 
a little ulcer was found, which Mr. Hutchinson decided was syphilitic. 
The diseased parts were then removed. By the fiftieth day the constitu- 
tional symptoms were well marked. Among the differences between 
vaccino-syphilis and vaccination ulcers the most important is perhaps that 
the chancre never develops before the fifteenth day, usually not until from 
three to five weeks, whereas the ulceration of ordinary vaccination is pres- 
ent by the twelfth or fifteenth day. The loss of substance in the chancre 
is usually quite superficial and the induration very parchment-like and 
specific, with but a slight inflammatory areola. The glandular swelling, too, 
is constant and indolent, while in the vaccination ulcer it is often absent, 
or, when present, chiefly inflammatory. 

Tuberculosis. — " No undoubted case of invaccinated tubercle was 
brought before the Eoyal Commission on Vaccination " (Acland). The risk 
of transmitting tuberculosis from the calf is so slight that it need not be 
considered. Tuberculosis in the calf is excessively rare, and "this almost 
inappreciable source of danger can be avoided by the simple precaution of 
not using the lymph from any calf until the animal has been killed and 
proved to be entirely free from disease " (Acland). 

The transmission of leprosy by vaccination is also open to serious doubt. 
In a few instances tetanus has developed during vaccination and proved 
fatal. 

(e) Influence of Vaccination upon other Diseases. — A quiescent malady 
may be lighted into activity, by vaccination. This has happened with con- 
genital syphilis, occasionally with tuberculosis. An old idea was preva- 
lent that vaccination had a beneficial influence upon existing diseases. 
Dr. Archer, the first medical graduate in the United States, recommended 
it in whooping-cough, and said that it had cured in his hands six or eight 
cases. 

Choice of Lymph. — Calf lymph should invariably be used, and it 
can now be obtained from perfectly reliable sources. The practice of arm- 
to-arm vaccination with humanized lymph should be abandoned. If bovine 
lymph is not available, then the humanized lymph should be taken on the 
eighth day, and only from perfectly formed, unbroken vesicles, which have 
had a typical course. Pricking or scratching the surface, the greatest care 
being taken not to draw blood, allows the lymph to* exude, and it may be 
collected on ivory points or in capillary tubes. The child from which the 
lymph is taken should be healthy, strong, and known to be of good stock, 
free from tuberculous or syphilitic taint. All possible sources of contamina- 
tion with pyogenic organisms are now obviated by the use of the glycerin- 
ated calf lymph which should come into general use. The Local Govern- 



VACCINIA— VACCINATION. 



73 



ment Board has recently issued a valuable report on the subject by Thome 
and Copeman, giving full details as to the method of preparation. In it 
the statement is made that, whereas it was usual to make the lymph from 
one calf serve for from 200 to 300 vaccinations, the glycerinated lymph will 
serve for from 4,000 to 5,000 vaccinations. 

Technique. — In the performance of the operation that part of the 
arm about the insertion of the deltoid is usually selected. Mothers " in 
society " prefer to have girl babies vaccinated on the leg. The skin should 
be cleansed and put upon the stretch. Then, with a lancet or the ivory 
point, cross-scratches should be made in one or more places. When the 
lymph has dried on the points it is best to moisten it in warm water. The 
clothing of the child should not be adjusted until the spot has dried, and 
it should be protected for a day or two with lint or a soft handkerchief. 
If erysipelas is prevalent, or if there are cases of suppuration in the same 
house, it is well to apply a pad of antiseptic cotton. Vaccination is usually 
performed at the second or third month. If unsuccessful, it should be re- 
peated from time to time. A person exposed to the contagion of small- 
pox should always be revaccinated. This, if successful, will usually pro- 
tect; but not always, as there are many instances in which, though the 
vaccination takes, variola also appears. 

The Value of Vaccination. — Sanitation cannot account for the 
diminution in small-pox and for the low rate of mortality. Isolation, of 
course, is a useful auxiliary, but it is no substitute. Vaccination is not 
claimed to be an invariable and permanent preventive of small-pox, but in 
an immense majority of cases successful inoculation renders the person for 
many years insusceptible. Communities in which vaccination and revac- 
cination are thoroughly and systematically carried out are those in which 
small-pox has the fewest victims. On the other hand, communities in which 
vaccination and revaccination are persistently neglected are those in which 
epidemics are most prevalent. In the German army the practice of revac- 
cination has stamped out the disease. Nothing in recent times has been 
more instructive in this connection than the fatal statistics of Montreal. 
The epidemic which started in 1870-'71 was severe in Lower Canada, and 
persisted in Montreal until 1875. A great deal of feeling had been 
aroused among the French Canadians by the occurrence of several serious 
cases of ulceration, possibly of syphilitic disease, following vaccination: 
and several agitators, among them a French physician of some standing, 
aroused a popular and widespread prejudice against the practice. There 
were indeed vaccination riots. The introduction of animal lymph was 
distinctly beneficial in extending the practice among the lower ( hisses, bill 
compulsory vaccination could not be carried out. Between the years 1876 
and 1884 a considerable unprotected population grew up and the materials 
were ripe for an extensive epidemic. The soil had been prepared with the 
greatest care, and it only needed the introduction of the seed, which in due 
time came, as already stated, with the Pullman-car conductor from Chi- 
cago, on the 28th of February, 1885. Within the next ten mouths thou- 
sands of persons were stricken with the disease, and 3,164 died. 

Although the effects of a single vaccination may wear out. as we say, 



74 



SPECIFIC INFECTIOUS DISEASES. 



and the individual again become susceptible to small-pox, yet the mortal- 
ity in such cases is very much lower than in persons who have never been 
vaccinated. The mortality in persons who have been vaccinated is from 
6 to 8 per cent, whereas in the unvaccinated it is at least 35 per cent. 
There is evidence that the greater the number of marks, the greater the 
protection in relation to small-pox; thus the English Vaccination Eeport 
states that out of 4,754 cases the death-rate with one mark was 7.6 per cent; 
with two marks, 7 per cent; with three marks, 4.2 per cent; with four marks, 
2.4 per cent. W. M. Welch's statistics of 5,000 cases on this point give with 
good cicatrices 8 per cent; with fair cicatrices, 14 per cent; with poor cica- 
trices, 27 per cent; post-vaccinal cases, 16 per cent; unvaccinated cases, 58 
per cent. 

VI. VARICELLA {Chicken-pox). 

Definition. — An acute contagious disease of children, characterized 
by an eruption of vesicles on the skin. 

Etiology. — The disease occurs in epidemics, but sporadic cases are 
also met with. It may prevail at the same time as small-pox or may fol- 
low or precede epidemics of this disease. An attack of chicken-pox is no 
protection against small-pox. It is a disease of childhood; a majority of 
the cases occur between the second and sixth years. It is rarely seen in 
adults. The specific germ has not yet been discovered. 

There can be no question that varicella is an affection quite distinct 
from variola and without at present any relation whatever to it. An at- 
tack of the one does not confer immunity from an attack of the other. 
The case which Sharkey reported is of special importance in this connec- 
tion. A boy, aged five, was admitted to St. Thomas' Hospital with a vesicu- 
lar eruption, and was isolated in a ward on the same floor as the small-pox 
ward. The disease was pronounced chicken-pox, however, by Sir Eisdon 
Bennett and Dr. Bristowe. The patient was then removed and vaccinated, 
with a result of four vesicles which ran a pretty normal course. On the 
eighth day from the vaccination the child became feverish. On the fol- 
lowing day the papules appeared and the child had a well-developed attack 
of small-pox with secondary fever. 

Symptoms. — After a period of incubation of ten or fifteen days the 
child becomes feverish and in some instances has a slight chill. There 
may be vomiting and pains in the back and legs. Convulsions are rare. 
The eruption usually develops within twenty-four hours. It is first seen 
upon the trunk, either on the back or on the chest. It may begin on the 
forehead and face. At first in the form of raised red papules, these are in 
a few hours transformed into hemispherical vesicles containing a clear or 
turbid fluid. As a rule there is no umbilication, but in rare instances the 
pocks are flattened, and a few may even be umbilicated. They are often 
ovoid in shape and look more superficial than the variolous vesicles. The 
skin in the neighborhood is neither infiltrated nor hyperamiic. At the 
end of thirty-six or forty-eight hours the contents of the vesicles are 
purulent. They begin to shrivel, and during the third and fourth days 



VARICELLA. 



75 



are converted into dark brownish crusts, which fall off and as a rule leave 
no scar. Fresh crops appear during the first two or three days of the ill- 
ness, so that on the fourth day one can usually see pocks in all stages of 
development and decay. They are always discrete and the number may 
vary from eight or ten to several hundreds. As in variola, a scarlatinal 
rash occasionally precedes the development of the eruption. The eruption 
may occur on the mucous membrane of the mouth, and occasionally in the 
larynx (D. H. Hall). 

There are one or two modifications of the rash which are interesting. 
The vesicles may become very large and develop into regular bullae, look- 
ing not unlike ecthyma or 'pemphigus (varicella bullosa). The irritation 
of the rash may be excessive, and if the child scratches the pocks ulcerat- 
ing sores may form, which on healing leave ugly scars. Indeed, cicatrices 
after chicken-pox are more common than after varioloid. The fever in 
varicella is slight, but it does not as a rule disappear with the appear- 
ance of the rash. The course of the disease is in a large majority of the 
cases favorable and no ill effects follow. The disease may recur in the 
same individual. There are instances in which a person has had three 
attacks. # 

In delicate children, particularly the tuberculous, gangrene (varicella 
escharotica) may occur about the vesicles (Hutchinson); or in other parts, 
as the scrotum. 

Cases have been described (Andrew) of hemorrhagic varicella with 
cutaneous ecchymoses and bleeding from the mucous membranes. 

Nephritis may occur. Infantile hemiplegia has developed during an 
attack of the disease. Death has followed in an uncomplicated case from 
extensive involvement of the skin (Msbet). 

The diagnosis is as a rule easy, particularly if the patient has been seen 
from the outset. When a case comes under observation for the first time 
with the rash well out, there may be considerable difficulty. The abun- 
dance of the rash on the trunk in varicella is most important. The pocks 
in varicella are more superficial, more bleb-like, have not so. deeply an 
infiltrated areola about them, and may usually be seen in all stages of de- 
velopment. They rarely at the outset have the hard, shotty feeling of those 
of small-pox. The general symptoms, the greater intensity of the onset, the 
prolonged period of invasion, and the more frequent occurrence of prodro- 
mal rashes in small-pox are important points in the diagnosis. 

No special treatment is required. If the rash is abundant on the face 
great care should be taken to prevent the child from scratching the pus- 
tules. A soothing lotion should be applied on lint. 



VII. SCARLET FEVER. 

Definition. — An infectious disease characterized by a diffuse exan- 
them and an angina of variable intensity. 

Etiology. — We owe the recognition of scarlet fever as a distinct dis- 
ease to Sydenham, before whose time it was confounded with measles. It 



76 



SPECIFIC INFECTIOUS DISEASES. 



is a widespread affection, occurring in nearly all parts of the globe and 
attacking all races. 

The disease occurs sporadically from time to time, and then under 
unknown conditions becomes widespread. Epidemics vary in severity. 

Among predisposing factors age is most important. A large propor- 
tion of the cases occur before the tenth year. Of an enormous number of 
fatal cases tabulated by Murchison over 90 per cent occurred in children 
under this age. Adults, however, are by no means exempt. Very young 
infants are rarely attacked. A certain number of those coming in contact 
with the disease escape. In a family of children all more or less exposed 
one or two may not contract scarlet fever, whereas, as a rule, in the case 
of measles all take it. The susceptibility seems to vary in families, and we 
meet occasionally with sad instances in which three or more members of a 
family succumb in rapid succession. 

Males and females are equally affected. 

Epidemics prevail at all seasons, but perhaps with greater intensity in 
autumn and winter. 

The contagion of scarlet fever is probably not developed until the erup- 
tion appears, and is particularly to be dreaded during desquamation. No 
doubt the poison is spread largely by the fine scaly particles which are 
diffused with the dust throughout the room. Even late in the disease, 
after desquamation has been apparently completed, a patient has con- 
veyed the contagion. The poison clings with great persistence to cloth- 
ing of all kinds and to articles of furniture in the room. In no disease is 
a greater tenacity displayed. Bedding and clothes which have been put 
away for months or even for years may, unless thoroughly disinfected, 
convey contagion. Physicians, nurses, and others in contact with the sick 
may carry the poison to persons at a distance. It is remarkable that in 
the case of physicians this does not more frequently occur. I know of 
but one instance in which I carried the contagion of this disease. The 
poison probably is not widely spread in the atmosphere. Observations 
have been recently made which indicate that it may be conveyed in milk. 
The epidemic investigated by Power and Klein in London in 1885 was 
traced by them to milk obtained from a dairy at Hendon, in which the 
cows were found to be suffering from a vesicular affection of the udder. 
The nature of this disease of the cow is doubtful, however. Crookshank 
holds that it was cow-pox, and had nothing to do with scarlet fever. 

Some writers maintain that scarlet fever may be associated with de- 
fective house-drainage. Possibly the virus may occasionally gain entrance 
in this way. 

One attack does not necessarily protect permanently. There are in- 
stances of one or even two recurrences. 

Surgical and puerperal scarlatinas, so called, demand a word under this 
section. While scarlet fever may attack a person after operation, or a 
woman in childbed, the majority of the cases described as such are, I be- 
lieve, forms of septicaemia. In the cases which I have seen the red 
rash was rarely so widespread as in scarlet fever; the tongue had not the 
special features, nor was the throat affected. Desquamation is no criterion, 



SCARLET FEVER. 



as it occurs whenever hyperemia of the skin has persisted for any length 
of time. It is interesting to note that these cases have become rare with 
the gradual disappearance of septicaemia. I. E. Atkinson suggests that 
in many cases these rashes are due to quinine. 

The specific germ is still doubtful. Recently Class, of Chicago, has 
found a diplococcus in 300 successive cases in the blood, in the throat 
secretion, and the scales. He states that it is pathogenic to mice, swine, 
and guinea pigs. A streptococcus has been recently described by Baginsky 
and Sommerfeld. These observations await confirmation. The throat 
and ear lesions are commonly due to the streptococcus, but in the infec- 
tious pavilions of hospitals the scarlet-fever cases are very apt to be com- 
plicated with true pharyngeal diphtheria. 

Morbid Anatomy. — Except in the hemorrhagic form, the skin 
after death shows no traces of the rash. . There are no specific lesions. 
Those which occur in the internal organs are due partly to the fever- and 
partly to infection with pus-organisms. 

The anatomical changes in the throat are those of simple inflamma- 
tion, follicular tonsillitis, and, in extreme grades, of pseudo-membranous 
angina. In severe cases there is intense lymphadenitis and much inflam- 
matory oedema of the tissues of the neck, which may go on to suppuration, 
or even to gangrene. Streptococci are found abundantly in the glands 
and in the areas of suppuration. Of changes in the digestive organs, a 
catarrhal state of the gastro-intestinal mucosa is not uncommon. The 
liver may show interstitial changes (Klein). The spleen is often enlarged. 

Endocarditis and pericarditis are not infrequent. Myocardial changes 
are less common. The renal changes are the most important, and have 
been thoroughly studied by Coats, Klebs, Wagner, and others. The spe- 
cial nephritis of scarlet fever will be considered with the diseases of the 
kidney. 

Affections of the respiratory organs are not frequent. When death 
results from the pseudo-membranous angina, broncho-pneumonia is not 
uncommon. Cerebro-spinal changes are rare. 

Symptoms. — Incubation. — " From one to seven days, oftenest two to 
four." 

Invasion. — The onset is as a rule sudden. It may be preceded by a 
slight, scarcely noticeable, indisposition. An actual chill is rare. Vomit- 
ing and, in young children, convulsions are common. The fever is in- 
tense; rising rapidly, it may on the first day reach 104° or even 105°. 
The skin is unusually dry and to the touch gives a sensation of very pun- 
gent heat. The tongue is furred, and as early as the first day there may 
be complaint of dryness of the throat. Cough and catarrhal symptoms 
are uncommon. The face is often flushed and the patient has all the ob- 
jective features of an acute fever. 

Eruption. — Usually on the second day, in some instances within twenty- 
four hours, the rash develops in the form of scattered red points on a deep 
subcuticular flush. It appears first on the neck and chest, and spreads so 
rapidly that by the evening of the second day it may have invaded tin 1 
entire skin. After persisting for two or three days it gradually fades. In 



TS 



SPECIFIC INFECTIOUS DISEASES. 



pronounced eases the rash at its height has a vivid scarlet hue, quite dis- 
tinctive and unlike that seen in any other eruptive disease. It is entirely 
hyperasmic, and the anaemia produced hy pressure instantly disappears. 
In a very intense rash there may be fine punctiform haemorrhages, which 
do not disappear on pressure. In some cases the rash does not become 
uniform but remains patchy, and intervals of normal skin separate large 
hyperaemic areas. Tiny papular elevations may sometimes be seen, but 
they are not so common as in measles. At the height of the eruption 
sudaminal vesicles may develop, the fluid of which may become turbid. 
The entire skin may at the same time be covered with small yellow vesi- 
cles on a deep red background — scarlatina miliaris. McCollom lays stress 
upon the appearance of a punctate eruption in the arm-pits, groins, and on 
the roof of the mouth as positive proof of scarlet fever. 

Occasionally there are pete.chiae, which in the malignant type of the 
disease become widespread and large. The eruption does not always ap- 
pear upon the face. There may 
be a good deal of swelling of the 
skin which feels uncomfortable 
and tense. The itching is vari- 
able; not as a rule intense at the 
height of the eruption. The 
rash can often be seen on the 
mucous membranes of the pal- 
ate, the cheeks, and the tonsils, 
giving to these parts a vivid red, 
punctiform appearance. The 
tongue at first is red at the tip 
and edges, furred in the centre; 
and through the white fur are 

Chart VIL-Scarlet fever. often seen the swollen red pa- 

pillae, which give the so-called 
" strawberry " appearance to the tongue. In a few days the " fur " des- 
quamates and leaves the surface red and rough, and it is this condition 
which some writers call the " strawberry," or, better, the " raspberry " 
tongue. Enlargement of the papillae was the only constant sign in 1,000 
cases (McCollom). The breath often has a very heavy, sweet odor. 
The pharyngeal symptoms are — 

1. Slight redness, with swelling of the pillars of the fauces and of the 
tonsils. 2. A more intense grade of swelling and infiltration of these parts 
with a follicular tonsillitis. 3. Membranous angina with intense inflam- 
mation of all the pharyngeal structures and swelling of the glands below 
the jaw, and in very severe cases a thick brawny induration of all the tissues 
of the neck. 

The fever, which sets in with such suddenness and intensity, may reach 
105° or even 106°. It persists with slight morning remissions, gradually 
declining with the disappearance of the rash. In mild cases the tempera- 
ture may not reach 103°; on the other hand, in very severe cases there may be 
hyperpyrexia, the thermometer registering 108° or before death even 109°. 




SCARLET FEVER. 



79 



The pulse presents the ordinary febrile characters, ranging in children 
from 120 to 150, or even higher. The respirations show an increase pro- 
portionate to the intensity of the fever. The gastro-intestinal symptoms 
are not marked after the initial vomiting, and food is usually well taken. 
In some instances there are abdominal pains. The edge of the spleen may 
, be palpable. The liver is not often enlarged. With the initial fever nervous 
symptoms are present in a majority of the cases; but as the rash comes 
out the headache and the slight nocturnal wandering disappear. The 
urine has the ordinary febrile characters, being scanty and high colored. 
Slight albuminuria is by no means infrequent during the stage of erup- 
tion. Careful examination of the urine should be made every day. There 
is no cause for alarm in the trace of albumin which is so often present, 
not even if it is associated with a few tube-casts. 

Desquamation. — With the disappearance of the rash and the fever the 
skin looks somewhat stained, is dry, a little rough, and gradually the upper 
layer of the cuticle begins to separate. The process usually begins about 
the neck and chest, and flakes are gradually detached. The degree and 
character of the desquamation bear some relation to the intensity of the 
eruption. When the latter has been very vivid and of long standing, large 
flakes may be thrown off. In rare instances the hair and even the nails 
have been shed. It must not be forgotten that there are cases in which 
the desquamation has been prolonged, according to Trousseau, even to 
the seventh or eighth week. The entire process lasts from ten to fifteen or 
| even twenty days. 

There are cases of exceptional mildness in which the rash may be 
scarcely perceptible. During epidemics, when several children of a house- 
hold are affected, it sometimes happens that a child sickens as if of scarlet 
fever, and has a sore throat and the " strawberry tongue " without the de- 
velopment of any rash. This is the so-called scarlatina sine eruptione. 

These mild cases of scarlet fever may be followed by the severest attacks 
of nephritis. A leucocytosis is usually present, which may be extreme in 
severe cases. 

MALIGNANT SCARLET FEVER. 

Atactic Form. — This presents all the characteristics of an acute intoxi- 
cation. The patient, overwhelmed by the intensity of the poison, may die 
within twenty-four or thirty-six hours. The disease sets in with great 
severity— high fever, extreme restlessness, headache, and delirium. The 
temperature may rise to 107° or even 108°, and rare cases have been ob- 
served in which the thermometer has registered even higher. Convulsions 
may occur in children. The initial delirium rapidly gives place to coma. 
The dyspnoea may be urgent; the pulse is very rapid and feeble. 

Hemorrhagic Form. — In some instances haemorrhages occur into the 
skin. There are hamiaturia and epistaxis. In the erythematous rash there 
are at first scattered petechia?, which gradually become more extensive, 
and ultimately the skin may be universally involved. Death may take 
place on the second or on the third day. While this form is perhaps 
more common in enfeebled children, I have twice known it to attack per- 
sons apparently in full health. 



80 



SPECIFIC INFECTIOUS DISEASES. 



Anginose Form. — The throat symptoms may appear early and progress 
rapidly. The fauces and tonsils are swollen. Membranous exudation 
occurs. It may extend to the posterior wall of the pharynx, forward into 
the mouth, and upward into the nostrils. The glands of the neck rapidly 
enlarge. Necrosis occurs in the tissues of the throat, the fcetor is extreme, 
the constitutional disturbance profound, and the child dies with the clin- 
ical picture of a malignant diphtheria. Occasionally the membrane ex- 
tends into the trachea and the bronchi. The Eustachian tubes and the 
middle ear are usually involved. When death does not take place rapidly 
from toxaemia there may be extensive abscess formation in the tissues of 
the neck and sloughing. In the separation of deep sloughs about the ton- 
sils the carotid artery may be opened, causing fatal haemorrhage. 

Complications and Sequelae. — (a) Nephritis. — At the height of 
the fever there is often a slight trace of albumin in the urine, which is 
not of special significance. In a majority of cases the kidneys escape with- 
out greater damage than occurs in other acute febrile affections. 

Nephritis is most common in the second or third week and may de- 
velop after a very mild attack. It may be delayed until the third or fourth 
week. As a rule, the earlier it develops the more severe it is. It varies 
greatly in intensity, and three grades of cases may be recognized: 

1. Very severe cases with suppression of urine or the passage of a small 
quantity of dark bloody urine laden with albumin and tube-casts. Vomit- 
ing is constant, there are convulsions, and the child dies with the symp- 
toms of acute uraemia. 

2. Less severe cases without any serious acute symptoms. There is a 
puffy appearance of the eyelids, with slight oedema of the feet; the urine 
is diminished in quantity, smoky in appearance, and contains albumin 
and tube-casts. The kidney symptoms then dominate the entire case, the 
dropsy persists, and there may be effusion into the serous sacs. The condi- 
tion may drag on and become chronic, or the patient may succumb to 
uraemic accidents. Fortunately, in a majority of the cases the disease yields 
to judicious treatment and recovery takes place. 

3. Cases so mild that they can scarcely be termed nephritis. The 
urine contains albumin and a few tube-casts, but rarely blood. The oedema 
is extremely slight or transient, and the convalescence is scarcely inter- 
rupted. Occasionally, however, in these mild attacks serious symptoms 
may supervene. (Edema of the glottis may prove rapidly fatal, and in one 
case of the kind a child under my care died of acute effusion into the 
pleural sacs. 

Occasionally oedema occurs without albuminuria or signs of nephritis. 
Possibly in some of these case the oedema may be hoemic and due to the 
anaemia; but there are instances in which marked changes have been found 
in the kidney after death, even when the urine did not show the features 
characteristic of nephritis. 

(b) Arthritis. — During the subsidence of the fever, rarely at its height, 
pains and swellings in the joints may develop and present all the charac- 
teristics of acute rheumatism. In all probability it is not, however, true 
rheumatism, but is analogous to gonorrhoeal arthritis. The effusion may 



SCARLET FEVER. 



81 



pass on to suppuration, in which case it most commonly involves only a 
single joint. 

(c) Cardiac Complications. — Simple endocarditis is not uncommon, 
and many cases of chronic valvular disease originate probably in a latent 
endocarditis during this disease. Malignant endocarditis is rare. Peri- 
carditis is probably not more frequent, but is less likely to be overlooked 
than endocarditis. It usually develops during convalescence; the effusion 
may be sero-fibrinous or purulent. The cardiac complications are some- 
times found in association with arthritis. Myocarditis is not uncommon. 

(d) Pleurisy may follow pneumonia, though this is rare. More often 
it occurs during convalescence, is insidious in its course, and as a rule 
purulent. This serious complication of scarlet fever is not sufficiently 
recognized. It was one upon which my teacher, E. P. Howard,* in Mon- 
treal, specially insisted in his lectures. Sheriff, in a number of the same 
journal, reports two cases, occurring at the same time in brothers, one of 
whom died suddenly after a slight exertion. 

(e) Ear Complications. — These are common and serious. They are 
due to extension of the inflammation from the throat through the Eu- 
stachian tubes, and rank among the most frequent causes of deafness. The 
severe forms of membranous angina are almost always associated with in- 
flammation of the middle ear, which goes on to suppuration and to per- 
foration of the drum. The suppuration may extend to the labyrinth and 
rapidly produce deafness. In other instances there is suppuration in the 
mastoid cells. ■ In the necrosis which follows the middle-ear disease, the 
facial nerve may be involved and paralysis follow. Later, still more seri- 
ous complications may follow the otitis, such as thrombosis of the lateral 
sinus, meningitis, or abscess of the brain. 

(/) Adenitis. — In comparatively mild cases of scarlet fever the sub- 
maxillary lymph-glands may be swollen. In severer cases the swelling of 
the neck becomes extreme and extends beyond the limits of the glands. 
Acute phlegmonous inflammations may occur, leading to widespread de- 
struction of tissue, in which vessels may be eroded and fatal haunorrhage 
ensue. The suppurative processes may also involve the retro-pharyngeal 
tissues. 

The swelling of the lymph-glands usually subsides, and within a lew- 
weeks even the most extensive enlargement gradually disappears. There 
are rare instances, however, in which the lymphadenitis becomes chronic, 
and the neck remains with a glandular collar which almost obliterates its 
outline. This may prove intractable to all ordinary measures of treat- 
ment. A case came under my observation in which, two years after scar- 
let fever, the neck was enormously enlarged and surrounded by a mass of 
firm brawny glands. 

(g) Nervous Complications. — Chorea occasionally develops in connec- 
tion with the arthritis and endocarditis. Sudden convulsions followed by 
hemiplegia may occur. Progressive paralysis of the limbs with wasting 
may develop with the features of a subacute, ascending spinal paralysis. 



* Canada Medical and Surgical Journal, December, 1872. 



82 



SPECIFIC INFECTIOUS DISEASES. 



Thrombosis of the cerebral veins may occur. Mental symptoms, mania and 
melancholia, have been described. 

(h) Other rare complications and sequelae are oedema of the eyelids, 
without nephritis (S. Philips), symmetrical gangrene, enteritis, noma, and 
perforation of the soft palate (Goodall). Pearson and Littlewood have 
reported a case of dry gangrene after scarlet fever in a boy of four, which 
developed on the ninth day of the disease, and involved both legs, neces- 
sitating amputation at the upper third of the tHighs. The child recovered. 

Diagnosis. — The diagnosis of scarlet fever is not difficult, but there 
are cases in which the true nature of the disease is for a time doubtful. 
The following are the most common conditions with which it may be 
confounded: 

1. Acute Exfoliating Dermatitis. — This pseudo-exanthem simulates scar- 
let fever very closely. It has a sudden onset, with fever. The eruption 
spreads rapidly, is uniform, and after persisting for five or six days begins 
to fade. Even before it has entirely gone, desquamation usually begins. 
Some of these cases can not be distinguished from scarlet fever in the 
stage of eruption. The throat symptoms, however, are usually absent, and 
the tongue rarely shows the changes which are so marked in scarlet fever. 
In the desquamation of this affection the hair and nails are commonly 
affected. It is, too, a disease liable to recur. Some of the instances of 
second and third attacks of scarlet fever have been cases of this form of 
dermatitis. 

2. Measles, which is distinguished by the longer period of invasion, 
the characteristic nature of the prodromes, and the later appearance of the 
rash. The greater intensity of the measly rash upon the face, the more 
papular character and the irregular crescentic distribution are distinguish- 
ing features in a majority of the cases. Other points are the absence in 
measles of the sore throat, the peculiar character of the desquamation, the 
absence of leucocytosis, and the presence of Koplik's sign. 

3. Rotheln. — The rash of rubella is sometimes strikingly like that of 
scarlet fever, but in the great majority of cases the mistake could not arise. 
In cases of doubt the general symptoms are our best guide. 

4. Septicemia. — As already mentioned, the so-called puerperal or sur- 
gical scarlatina shows an eruption which may be identical in appearance 
with that of true scarlet fever. 

5. Diphtheria. — The practitioner may be in doubt whether he is deal- 
ing with a case of scarlet fever with intense membranous angina, a true 
diphtheria with an erythematous rash, or coexisting scarlet fever and 
diphtheria. In the angina occurring early in, and during the course of 
scarlet fever, though the clinical features may be those of true diphtheria, 
Loeffler's bacilli are rarely found. On the other hand, in the membranous 
angina occurring during convalescence, the bacilli are usually present. The 
rash in diphtheria is, after all, not so common, is limited usually to the 
trunk, is not so persistent, and is generally darker than the scarlatinal rash. 

Scarlatina and diphtheria may coexist, but in a case presenting wide- 
spread erythema and extensive membranous angina with Loeffler's bacilli, 
it would puzzle Hippocrates to say whether the two diseases coexisted, or 



SCARLET FEVER. 



83 



whether it was only an intense scarlatinal rash in diphtheria. Desquama- 
tion occurs in either case. The streptococcus angina is not so apt to ex- 
tend to the larynx, nor are recurrences so common; but it is well to bear 
in mind that general infection may occur, that the membrane may spread 
downward with great rapidity, and, lastly, that all the nervous sequelae of 
the Klebs-Loeffler diphtheria may follow the streptococcus form. 

6. Drug Rashes. — These are partial, and seldom more than a transient 
hyperemia of the skin. Occasionally they are diffuse and intense, and in 
such cases very deceptive. They are not associated, however, with the 
characteristic symptoms of invasion. There is no fever, and with care the 
distinction can usually be made. They are most apt to follow the use of 
belladonna, quinine, and iodide of potassium. 

Coexistence of other Diseases. — Of 48,366 cases of scarlet fever in the 
Metropolitan Asylum Board Hospitals which were complicated by some 
other disease, in 1,094 cases the secondary infection was diphtheria, in 899 
cases chicken-pox, in 703 measles, in 404 whooping-cough, in 55 erysipelas, 
in 11 enteric fever, and in 1 typhus fever (F. F. Caiger). 

Hoiv long is a Child Infective? — Usually after desquamation is com- 
plete, in four or five weeks the danger is over, but the occurrence of so-called 
" return cases " show that patients remain infective even when free from 
desquamation. In 1894, with 2,593 patients from the Glasgow fever 
hospitals sent to their homes convalescent, fresh cases appeared in 70 
of the houses (Chalmers). With 15,000 cases submitted to an average 
period of isolation of forty-nine days or under, the percentage of return 
cases was 1.86; with an average period of fifty to fifty-six days, the per- 
centage was 1.12; where the isolation extended to between fifty-seven and 
sixty-five days, the percentage of return cases was 1 (Neech). This 
author suggests eight weeks as a minimum and thirteen weeks as a maxi- 
mum. Special care should be taken of cases with rhinorrhcea and otorrhcea. 

Prognosis. — Epidemics differ in severity and the mortality is ex- 
tremely variable. Among the better classes the death-rate is much lower 
than in hospital practice. There are physicians who have treated consecu- 
tively a hundred or more cases without a death. On the other hand, in 
hospitals and among the poorer classes the death-rate is considerable, 
ranging from 5 or 10 per cent in mild epidemics to 20 or 30 per cent in the 
very severe. In 1,000 cases reported from the Boston City Hospital by 
McCollom, the death-rate was 9.8 per cent. The younger the child the 
greater the danger. In infants under one year the death-rate is very high. 
The great proportion of fatal cases occurs in children under six years of 
age. The unfavorable symptoms are very high fever, early mental disturb- 
ance with great jactitation, the occurrence of haemorrhages (cutaneous or 
visceral), intense membranous angina with cervical bubo, and signs of 
laryngeal obstruction. 

Nephritis is always a serious complication and when setting in with 
suppression of the urine may quickly prove fatal. It is noteworthy, how- 
ever, that a large majority of the cases of scarlatinal nephritis recover. 

Treatment. — The disease can not be cm Bhort. In the presence of 
the severer forms we are still too often helpless. There is no disease, how- 



84 



SPECIFIC INFECTIOUS DISEASES. 



ever, in which the successful issue and the avoidance of complications de- 
pends more upon the skilled judgment of the physician and the care with 
which his instructions are carried out. 

The child should be isolated and placed in charge of a competent 
nurse. The temperature of the room should be constant and the ventila- 
tion thorough. The child should wear a light flannel night-gown, and 
the bedclothing should not be too heavy. The diet should consist of milk, 
broths, and fresh fruits; water should be freely given. With the fall of 
the temperature, the diet may be increased and the child may gradually 
return to ordinary fare. When desquamation begins the child should be 
thoroughly rubbed every day, or every second day, with sweet oil, or car- 
bolated vaseline, or a 5-per-cent hydro-naphthol soap, which prevents the 
drying and the diffusion of the scales. An occasional warm bath may 
then be given. At any time during the attack the skin may be sponged 
with warm water. The patient may be allowed to get up after the tem- 
perature has been normal for ten clays, but for at least three weeks from 
this time great care should be exercised to prevent exposure to cold. It 
must not be forgotten, also, that the renal complications are very apt to 
develop during the convalescence, and after all danger is apparently past. 
Ordinary cases do not require any medicine, or at the most a simple fever 
mixture, and during convalescence a bitter tonic. The bowels should be 
carefully regulated. 

Special symptoms in the severe cases call for treatment. 

When the fever is above 103° the extremities may be sponged with 
tepid water. In severe cases, with the temperature rapidly rising, this will 
not suffice, and more thorough measures of hydrotherapy should be prac- 
tised. With pronounced delirium and nervous symptoms the cold pack 
should be used. When the fever is rising rapidly but the child is not 
delirious, he should be placed in a warm bath, the temperature of which 
can be gradually lowered. The bath with the water at 80° is beneficial. 
In giving the- cold pack a rubber sheet and a thick layer of blankets should 
be spread upon a sofa or a bed, and over them a sheet, wrung out of cold 
water. The naked child is then laid upon it and wrapped in the blankets. 
An intense glow of heat quickly follows the preliminary chilling, and from 
time to time the blankets may be unfolded and the child sprinkled with 
cold water. The good effects which follow this plan of treatment are 
often striking, particularly in allaying the delirium and jactitation, and 
procuring quiet and refreshing sleep. Parents will object less, as a rule, 
to the warm bath gradually cooled than to any other form of hydrotherapy. 
The child may be removed from the warm bath, placed upon a sheet 
wrung out of tolerably cold water, and then folded in blankets. The ice- 
cap is very useful and may be kept constantly applied in cases in which 
there is high fever. Medicinal antipyretics are not of much service in 
comparison with cold water. 

The throat symptoms, if mild, do not require much treatment. If 
severe, the local measures mentioned under diphtheria should be used. 
Cold applications to the neck are to be preferred to hot, though it is some- 
times' difficult to get a child to submit to them. In connection with the 



MEASLES. 



85 



throat, the ears should be specially looked after, 'and a careful disinfection 
of the mouth and fauces by suitable antiseptic solutions should be prac- 
tised. When the inflammation extends through the tubes to the middle 
ear, the practitioner should either himself examine daily the condition of 
the drum, or, when available, a specialist should be called in to assist him 
in the case. The careful watching of this membrane day by day and the 
puncturing of it if the tension becomes too great may save the hearing of 
the child. With the aid of cocaine the drum is readily punctured. The 
operation may be repeated at intervals if the pain and distention return. 
No complication of the disease is more serious than this extension of the 
inflammatory process to the ear. 

The nephritis should be dealt with as in ordinary cases; indications 
for treatment will be found under the appropriate section. It is worth 
mentioning, however, that J accoud insists upon the great value of milk diet 
in scarlet fever as a preventive of nephritis. 

Among other indications for treatment in the disease is cardiac weak- 
ness, which is usually the result of the direct action of the poison, and is 
best met by stimulants. 

Many specifics have been vaunted in scarlet fever, but they are all 
useless. 

VIII. MEASLES. 

Definition. — An acute, highly contagious disorder, characterized by 
an initial coryza and a rapidly spreading eruption. 

Etiology. — The infection of measles is very intense and immunity 
against attack not nearly so common as in scarlet fever. It is a disease of 
childhood, but unprotected adults are liable to the infection. Indeed, 
measles is more frequent in adults than is scarlet fever. Within the first 
six months of life the liability is not so marked, though infants of a month 
or three weeks may be attacked. The sexes are equally affect^!. The con- 
tagion is communicated by the breath and by the secretions, particularly 
those of the nose. It may be conveyed by a third person and by fomites. 

The disease is practically endemic in large centres of population, and 
from time to time spreads and prevails epidemically. It occurs at all sea- 
sons, but prevails more extensively during the colder months. There is 
no infectious disease in which recurrence is more frequent. There may 
be a second, third, or even a fourth attack. 

The contagium of the disease is unknown. No one of the various organ- 
isms which have been described meets the requirements of Koch's law. 

Morbid Anatomy.— Ji [easles itself rarely kills, but the complica- 
tions and sequelae combine to make it a very fatal affection in children. 
There are no characteristic post-mortem appearances. The skin changes 
are those associated with an intense hyperaemia. 

There is a catarrhal condition of the mucous membranes, particularly 
of the bronchi. The fatal cases show almost invariably either broncho- 
pneumonia, capillary bronchitis with patches of collapse, or less frequently 
lobar pneumonia. The bronchial glands are invariably swollen. Pleurisy 



86 



SPECIFIC INFECTIOUS DISEASES. 



is less common. During convalescence from measles there is a special lia- 
bility to tuberculous invasion, and tuberculous broncho-pneumonia claims 
a large number of victims. The bronchial glands may also be affected. 

The gastro-intestinal mucosa may be hypersemic. Swelling of Peyer's 
glands is not at all uncommon and may reach a very intense grade in the 
patches. 

Symptoms. — Incubation. — "From seven to eighteen days; oftenest 
fourteen." The disease has been frequently inoculated. In such cases 
the incubation period is less than ten days. 

Invasion. — The disease usually begins with symptoms of a feverish 
cold. There are shiverings (not often a definite chill), marked coryza, 
sneezing, running at the nose, redness of the eyes and lids, with photo- 
phobia, and within twenty-four hours cough. These early catarrhal symp- 
toms are more marked in measles than in any other infectious disease of 
children. There may be the symptoms so commonly associated with an 
on-coming fever — nausea, vomiting, and headache. The tongue is furred. 
Examination of the throat may show a reddish hyperemia or in some in- 
stances a distinct punctiform rash. 
Occasionally this spreads over the 
whole mucous membrane of the 
mouth with the exception of the 
tongue. The temperature at this 
stage is usually high, reaching from 
103° to 104°, ascending gradually 
through the second and third days. 

Eruption. — Usually on the 
fourth day, when the fever and 
general symptoms have reached 
their height, the rash appears 
upon the cheeks or forehead in 
the form of small red papules, 
which increase in size and spread 
over the neck and thorax. "When 
the eruption becomes well devel- 
Chart VIII.— Measles. 0 ped the face is swollen and cov- 

ered with reddish blotches, which 
often have rounded or crescentic outlines. Here and there is an intervening 
portion of unaffected skin. At this stage the cervical lymph-glands may 
be slightly swollen and sore; sometimes also the glands in the groins, 
axillae, and at the elbows. The papules can now be felt with the finger. 
Sometimes they are quite shotty, but do not extend deep into the skin. On 
the trunk and extremities the swelling of the skin is not so noticeable, 
the color of the rash not so intense and often less uniform. The mottled, 
blotchy character of the rash appears most clearly on the chest or the abdo- 
men. The rash is hyperaemic and disappears on pressure, but in the more 
malignant cases it may become hemorrhagic. The general symptoms do 
not abate with the occurrence of the eruption. They persist until the end 
of the fifth or the sixth day, when in the majority of the cases all the symp- 



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MEASLES. 



87 



toms become mitigated. Among the peculiarities of the rash may be men- 
tioned the development of numerous miliary vesicles and the occurrence of 
petechia?, which are seen occasionally even in cases of moderate severity. 
Preliminary rashes are sometimes seen, chiefly erythematous. 

Buccal spots were described by Filatow in 1895, and by Koplik in 1896. 
They are seen on a level with the bases of the lower milk molars on either 
side, or at the line of junction of the molars when the jaws are closed. 
They are white or bluish-white specks, surrounded by red areolae. Their 
importance depends upon the fact of their remarkable constancy in the dis- 
ease, and their occasional appearance before the exanthem. 

After persisting for two or three days the rash gradually fades and 
desquamation occurs in the form of very fine branny scales. 

Atypical cases are common. The rash may appear early, within 
thirty-six hours of the onset of the symptoms; or, on the other hand, it 
may be delayed until the sixth day. When many cases occur in a house- 
hold, one of the children may have all the initial symptoms and " sicken 
for the disease," as it is said, but no eruption appears. 

Hemorrhagic measles, the morbilli hcemorrhagici, is seen occasionally 
in institutions, particularly when the hygienic surroundings are bad, or one 
or two cases develop during an epidemic. It has been frequently seen in 
camps and when the disease is freshly imported into a native population, 
as in the Fiji Islands. 

The disease sets in with great intensity, the rash becomes petechial, 
haemorrhages occur from the mucous membranes, the constitutional depres- 
sion is very great, and death occurs early from toxaemia. 

Complications and Sequelae. — The existing bronchitis is apt to 
extend into the smaller tubes and lead to collapse and broncho-pneumonia. 
When limited in extent, this causes only aggravation of the cough and per- 
sistence of the fever (symptoms which gradually abate), and convalescence 
is rapid; but in debilitated children, more particularly in institutions and 
among the lower classes, this complication is extremely grave and is re- 
sponsible for the high death-rate from measles in the community. In 
some instances the clinical picture is that of a suffocative catarrh, the 
result of a widespread involvement of the smaller tubes. The description 
of the condition will be found under Broncho-pneumonia. Lobar pneu- 
monia is less common and perhaps less dangerous. 

Laryngitis is not uncommon: the voice becomes husky and the cough 
croupy in character. (Edema of the glottis is very rare. Pseudo-mem- 
branous inflammation of the pharynx and larynx may occur and prove 
fatal. In debilitated infants severe stomal it is, cancrum oris, or ulcerative 
vulvitis may develop. 

Catarrhal inflammation of the middle ear is not very uncommon, ami 
may proceed to suppuration and to perforation of the drum. r l ne con- 
junctival catarrh rarely leads to further trouble, though occasionally the 
inflammation becomes purulent. 

Intestinal catarrh is common in some epidemics, and there may he the 
symptoms of acute colitis. 
G 



88 



SPECIFIC INFECTIOUS DISEASES. 



Nephritis is an exceedingly rare complication. 

Of the sequelae of measles, tuberculosis is the most important — either 
an involvement of the bronchial glands, a miliary tuberculosis, or a tuber- 
culous broncho-pneumonia. Arthritis is rare. I have known anchylosis of 
the jaw to follow measles in a child of four years. Relapse may occur. 

Among the rarer sequelae are paralyses. Hemiplegia is very rare, but 
cases of paraplegia have been described. Thomas Barlow reports a fatal 
case in which the symptoms occurred early, the paralysis extended rapidly 
and involved the upper limbs, and death took place on the eleventh day. 
Marked vascular changes were found in the gray matter of the spinal cord, 
and were believed to depend on an early disseminated myelitis. Examina- 
tion of the peripheral nerves was not made. While some of these cases are 
due to an ascending myelitis, others are probably the result of a post- 
febrile polyneuritis. 

Diagnosis. — From scarlet fever, with which it is most likely to be 
confounded, measles is distinguished by the longer initial stage with char- 
acteristic symptoms, and the blotchy irregular character of the rash, which 
is so unlike the diffuse uniform erythema of scarlet fever. Occasionally 
in measles, when the throat is very sore and the eruption pretty diffuse, 
there may at first be difficulty in determining which disease is present, but 
a few days should suffice to make the diagnosis clear. As a rule there 
is no leucocytosis. It may be extremely difficult to distinguish from rotheln. 
I have more than once known practitioners of large experience unable 
to agree upon a diagnosis. The shorter prodromal stage, the slighter fever 
in many cases, are perhaps the most important features. It is difficult to 
speak definitely about the distinctions in the rash, though perhaps the 
more uniform distribution and the absence of the crescentic arrangement 
are more constant in rotheln. In Africans the disease is easily recognized, 
the papules stand out with great plainness, often in groups; the hyperemia 
is to be seen on all but the very black skins. The distribution of the 
rash, the coryza, and the rash in the mouth are important points. The 
conditions under which measles may be mistaken for small-pox have 
already been described. Of drug eruptions, that induced by copaiba is very 
like measles, but is readily distinguished by the absence of fever and 
catarrh. Occasionally erythema multiforme may simulate measles. 

Prognosis. — The mortality bills of large cities show what a serious 
disease measles is in a community. Among the eruptive fevers it ranks 
third in the death-rate. The mortality from the disease itself is not high, 
but the pulmonary complications render it one of the most serious of the 
diseases of children. 

In some epidemics the disease is of great severity. In institutions and 
in armies the death-rate is often high. The fever itself is rarely a source 
of danger. The extension of the catarrhal symptoms to the finer bronchial 
tubes is the most serious indication. 

Treatment. — Confinement to bed in a well-ventilated room and a 
light diet are the only measures necessary in cases of uncomplicated measles. 
The fever rarely reaches a dangerous height. If it does it may be lowered 



RUBELLA. 



89 



by sponging or by the tepid bath gradually reduced. If the rash does not 
come out well, warm drinks and a hot bath will hasten its maturation. 
The bowels should be freely opened. If the cough is distressing, pare- 
goric and a mixture of ipecacuanha wine and squills should be given. The 
patient should be kept in bed for a few days after the fever subsides. Dur- 
ing desquamation the skin should be oiled daily, and warm baths given 
to facilitate the process. The convalescence from measles is the most 
important stage of the disease. Watchfulness and care may prevent seri- 
ous pulmonary complications. The frequency with which the mothers 
of children with simple or tuberculous broncho-pneumonia tell us that 
66 the child caught cold after measles," and the contemplation of the mor- 
tality bills should make us extremely careful in our management of this 
affection. 

IX. RUBELLA (Rdthehi, German Measles). 

This exanthem has also the names of rubeola notha, or epidemic rose- 
ola, and, as it is supposed to present features common to both, has been also 
known as hybrid measles or hybrid scarlet fever. It is now generally 
regarded, however, as a separate and distinct affection. 

Etiology. — It is propagated by contagion and spreads with great 
rapidity. It frequently attacks adults, and the occurrence of either measles 
or scarlet fever in childhood is no protection against it. The epidemics 
of it are often very extensive. 

Symptoms. — These are usually mild, and it is altogether a less seri- 
ous affection than measles. Very exceptionally, as in the epidemics studied 
by Cheadle, the symptoms are severe. 

The stage of incubation ranges from ten to twelve days. 

In the stage of invasion there are chilliness, headache, pains in the 
back and legs, and coryza. A macular, rose-red eruption on the throat is 
a constant symptom, on which account, indeed, it was that it was originally 
regarded as a hybrid, having the sore throat of scarlet fever and the rash 
of measles. There may be very slight fever. In 30 per cent of Edwards's 
cases the temperature did not rise above 100°. The duration of this stage 
is somewhat variable. The rash usually appears on the first day. some 
writers say on the second, and others again give the duration of the Btage 
of invasion as three days. Griffith places it at two days. The erupt ion 
comes out first on the face, then on the chest, and gradually extends so 
that within twenty-four hours it is scattered over the whole body. It may 
be the first symptom noted by the mother. The eruption consists of a 
number of round or oval, slightly raised spots, pinkish-red in color, usually 
discrete, but sometimes confluent. 

The color of the rash is somewhat brighter than in measles. The 
patches are less distinctly crescent ic. After persisting for two or three 
days (sometimes longer), it gradually fades and there is a slight furfura- 
ceous desquamation. The rash persists as a rule longer than in scarlet 
fever or measles, and the skin is slightly stained after it. The Lymphatic 
glands of the neck are frequently swollen, and. when the eruption i< very 
intense and diffuse, the lymph-glands in the other parts of the body. 



90 



SPECIFIC INFECTIOUS DISEASES. 



There are no special complications. The disease usually progresses 
favorably; but in rare instances, as in those reported by Cheadle, the 
symptoms are of greater severity. Albuminuria may occur and even 
nephritis. Pneumonia and colitis have been present in some epidemics. 
Icterus has been seen. 

Diagnosis. — The slightness of the prodromal symptoms, the mild- 
ness, or the absence of the fever, the more diffuse character of the rash, 
its rose-red color, and the early enlargement of the cervical glands, are the 
chief points of distinction between rotheln and measles. Dukes has de- 
scribed a " fourth disease," distinguished from rotheln chiefly by a more 
diffuse rash and a longer period of incubation. 

The treatment is that of a simple febrile affection. 

X. EPIDEMIC PAROTITIS {Mumps). 

Definition. — An infectious disease, characterized by inflammation of 
the parotid gland. The testes in males and the ovaries and breasts in 
females are sometimes involved. 

Etiology. — The nature of the virus is unknown. 

The affection has all the characters of an epidemic disease. It is said 
to be endemic in certain localities, and probably is so in large centres of 
population. At certain seasons, particularly in the spring and autumn 
months, the number of cases increases rapidly. It is met most frequently 
in childhood and adolescence. Very young infants and adults are seldom 
attacked. Males are somewhat more frequently affected than females. In 
institutions and schools the disease has been known to attack over 90 per 
cent of all the children. It may be curiously localized in a city or district. 
The disease is contagious and spreads from patient to patient. 

A remarkable idiopathic, non-specific parotitis may follow injury or 
disease of the abdominal or pelvic organs (see Diseases of the Salivary 
Glands). 

Symptoms. — The period of incubation is from two to three weeks, 
and there are rarely any symptoms during this stage. The invasion is 
marked by fever, which is usually slight, rarely rising above 101°, but in 
exceptionally severe cases going up to 103° or 104°. The child complains 
of pain just below the ear on one side. Here a slight swelling is noticed, 
which increases gradually, until, within forty-eight hours, there is great 
enlargement of the neck and side of the cheek. The swelling passes for- 
ward in front of the ear, and back beneath the sterno-mastoid muscle. The 
other side usually becomes affected within a day or two. The other sali- 
vary glands are rarely involved. The greatest inconvenience is experi- 
enced in taking food, for the patient is unable to open the mouth, and 
even speech and deglutition become difficult. There may be an increase 
in the secretion of the saliva, but the reverse is sometimes the case. There 
is seldom great pain, but, instead, an unpleasant feeling of tension and 
tightness. There may be earache, even otitis media, and slight impairment 
of hearing. 

After persisting for from seven to ten days, the swelling gradually 



EPIDEMIC PAROTITIS. 



91 



subsides and the child rapidly regains his strength and health and is none 
the worse for the attack. 

Occasionally the disease is very severe and characterized by high fever, 
delirium, and great prostration. The patient may even lapse into a typhoid 
condition. 

Orchitis. — Excessively rare before puberty, it develops usually as the 
parotitis subsides, or indeed a week or ten days later. One or both testicles 
may be involved. The swelling may be great, and occasionally effusion 
takes place into the tunica vaginalis. The orchitis may develop before 
the parotitis, or in rare instances may be the only manifestation of the 
infection {orchitis parotidea). The inflammation increases for three or four 
days, and resolution takes place gradually. There may be a muco-purulent 
discharge from the urethra. In severe cases atrophy may follow, fortunately 
as a rule only in one organ; occurring in both before puberty the natural 
development is usually checked. Even when both testicles are atrophied 
and small, sexual vigor may be retained. The proportion of cases of orchitis 
varies in different epidemics; 211 cases occurred in 699 cases, and 103 cases 
of atrophy followed 163 instances of orchitis (Comby). 

A vulvo-vaginitis sometimes occurs in girls, and the breasts may be- 
come enlarged and tender. Mastitis has been seen in boys. Involvement 
of the ovaries is rare. 

Complications and Sequelae. — Of these the cerebral affections 
are perhaps the most serious. As already mentioned, there may be de- 
lirium and high fever. In rare instances meningitis has been found. 
Hemiplegia and coma may also occur. A majority of the fatal cases are 
associated with meningeal symptoms. These, of course, are Very rare in 
comparison with the frequency of the disease; yet, in the Index Catalogue, 
under this caption, there are six fatal cases mentioned. In some epi- 
demics the cerebral complications are much more marked than in others. 
Acute mania has occurred, and there are instances on record of insanity 
following the disease. 

• Arthritis, albuminuria, even acute uraemia with convulsions, endocar- 
ditis, facial paralysis, hemiplegia, and peripheral neuritis are occasional 
complications. 

Suppuration of the gland is an extremely rare complication in genuine 
idiopathic mumps. Gangrene has occasionally occurred. The special 
senses may be seriously involved. Many cases of deafness have been de- 
scribed in connection with or following mumps. It, unfortunately, may 
be permanent. Affections of the eye are rare, but atrophy of the optic 
nerve has been described. The lachrymal glands may be involved. 

Eelapse may occur, even two or three, and chronic hypertrophy of the 
gland may follow. 

The diagnosis of the disease is usually easy. The position of the 
swelling in front of and below the ear and the elevation of the lohe on the 
affected side definitely fix the locality of the swelling. In children in- 
flammation of the parotid, apart from ordinary mumps, is excessively rare. 

Treatment. — It is well to keep the patienl in bed during the hei 
of the disease. The bowels should be freely opened, and the patieni given 



92 



SPECIFIC INFECTIOUS DISEASES. 



a light liquid diet. No medicine is required unless the fever is high, in 
which case aconite may be given. Cold compresses may be placed on the 
gland, but children, as a rule, prefer hot applications. A pad of cotton 
wadding covered with oiled silk is the best application. Suppuration is 
hardly ever to be dreaded, even though the gland become very tense. Should 
redness and tenderness develop, leeches may be used. With delirium and 
head symptoms the ice-cap may be applied. In a robust subject, unless 
the signs of constitutional depression are extreme, a free venesection may 
do good. For the orchitis, rest, with support and protection of the swollen 
gland with cotton-wool, is usually sufficient. 



XI. WHOOPING COUGH. 

Definition. — A specific affection characterized by convulsive cough 
and a long-drawn inspiration, during which the " whoop " is produced. 

Etiology. — The disease occurs in epidemic form, but sporadic cases 
appear in a community from time to time. It is directly contagious from 
person to person; but dwelling-rooms, houses, school-rooms, and other 
localities may be infected by a sick child. It is, however, in this way less 
contagious than other diseases, and is probably most often taken by direct 
contact. Koplik, Czaplewski, and Hensel have described a bacillus in the 
sputum, which is probably the specific organism. The bacilli are pres- 
ent in the mucous clumps, with other forms as a rule, but they can be sepa- 
rated by proper means. Koplik found them in 13 of 16 cases of whooping- 
cough. It is a small bacillus with rounded ends, a little larger than the 
influenza bacillus. It is a facultative anaerobe, and is pathogenic for mice. 
There are still doubtful points regarding the organism. Epidemics prevail 
for two or three months, usually during the winter and spring, and have 
a curious relation to other diseases, often preceding or following epidemics' 
of measles, less frequently of scarlet fever. 

Children between the first and second dentitions are commonly affected. 
Sucklings are, however, not exempt, and I have seen very severe attacks 
in infants under six weeks. It is stated that girls are more subject to the 
disease than boys. Adults and old people are sometimes attacked, and in 
the aged it may be a very serious affection. Many persons possess immu- 
nity against the disease, and, though frequently exposed, escape. As a 
rule, one attack protects. Delicate anaemic children with nasal or bron- 
chial catarrh are more subject to the disease than others. According to 
the United States Census Eeports, the disease is more than twice as fatal 
in the negro race than in others. 

Morbid Anatomy. — Whooping-cough itself has no special patho- 
logical changes. In fatal cases pulmonary complications, particularly 
broncho-pneumonia, are usually present. Collapse and compensatory em- 
physema, vesicular and interstitial, are found, and the tracheal and bron- 
chial glands are enlarged. 

Symptoms. — Catarrhal and paroxysmal stages can be recognized. 
There is a variable period of incubation of from seven to ten days. In 



WHOOPING-COUGH. 



93 



the catarrhal stage the child has the symptoms of an ordinary cold, which 
may begin with slight fever, running at the nose, injection of the eyes, 
and a bronchial cough, usually dry, and sometimes giving indications of a 
spasmodic character. The fever is usually not high, and slight attention 
is paid to the symptoms, which are thought to be those of a simple catarrh. 
After lasting for a week or ten days, instead of subsiding, the cough be- 
comes worse and more convulsive in character. 

The paroxysmal stage, marked by the characteristic cough, dates from 
the first appearance of the " whoop/' The fit begins with a series of from 
fifteen to twenty short coughs of increasing intensity, and then with a 
deep inspiration the air is drawn into the lungs, making the " whoop," 
which may be heard at a distance and from which the disease takes its 
name. This loud inspiratory sound may sometimes precede the series of 
spasmodic expiratory efforts. Several coughing-fits may succeed each other 
until a tenacious mucus is ejected. This may be small in amount, but 
after a series of coughing-fits a considerable quantity may be expec- 
torated. Not infrequently it' is brought up by vomiting or by a combina- 
tion of cough and regurgitation. There may be only four or five of these 
attacks in the day, or in severe cases they may recur every J^alf-hour. Dur- 
ing the paroxysm the thorax is very strongly compressed by the powerful 
■expiratory efforts, and, as very little air passes in through the glottis, there 
are signs of defective aeration of the blood; the face becomes swollen and 
congested, the veins are prominent, the eyeballs protrude, and the con- 
junctiva? become deeply engorged. Suffocation indeed seems imminent, 
when with a deep, crowing inspiration air enters the lungs and the color 
is quickly restored. Children are usually terrified at the onset, and run 
at once to the mother or nurse to be supported during the attack. Few 
•diseases are more painful to witness. In severe paroxysms vomiting is 
frequent and the sphincters may be opened. The urine is said to be of 
high specific gravity (1022-1032), pale yellow, and to contain much uric 
acid. 

An ulcer under the tongue is a very common event, and was thought 
at one time to be the cause of the disease. 

During the attack, if the chest be examined, the resonance is defective 
in the expiratory stage, full and clear during the deep, crowing inspiration; 
but on auscultation during the latter there may be no vesicular murmur 
heard, owing to the slowness with which the air passes the narrowed glot- 
tis. Bronchial rales are occasionally heard. 

Among circumstances which precipitate a paroxysm are emotion, such 
as crying, and any irritation about the throat. Even the ad of swallowing 
sometimes seems sufficient. In a close dusty atmosphere the coughing- 
fits are more frequent. After lasting for three or lour weeks the attacks 
become lighter and finally cease. In cases of ordinary severity the course 
of the disease is rarely under six weeks. 

The complications and sequela? of whooping-cough are important. Dur- 
ing the extensive venous congestion luvmorrhages are very apt to occur 
in the form of petechia?, particularly about the forehead, ecchymosis of 
the conjunctiva?, epistaxis, and occasionally hemoptysis. 1 lemorrhaiie 



94 



SPECIFIC INFECTIOUS DISEASES. 



from the bowels is rare. Convulsions are not very uncommon, due perhaps 
to the extreme engorgement of the cerebral cortex. Very rarely hemiplegia 
or monoplegia follows. Sudden death has been caused by extensive sub- 
dural haemorrhage. Whooping-cough must be regarded as a very unusual 
cause of cerebral palsy in children. It was associated with 3 of my series 
of 120 cases, but in none of them did the hemiplegia come on during the 
paroxysm, as in a case reported by S. West. Bernhardt has described an 
acutely developing spastic paraplegia, 

The persistent vomiting may induce marked anaemia and wasting. The 
pulmonary complications which follow whooping-cough are extremely seri- 
ous. During the severe coughing-spells interstitial emphysema may be 
induced, more rarely pneumothorax. I saw one instance in which rupture 
occurred, evidently near the root of the lung, and the air passed along the 
trachea and reached the subcutaneous tissues of the neck, a condition 
which has been known to become general. Broncho-pneumonia, with its 
accompanying collapse, is the most frequent pulmonary complication and 
carries off a large number of children. It may be simple, but in a con- 
siderable proportion of the cases the process is tuberculous. Pleurisy is 
sometimes met with and occasionally lobar pneumonia. Enlargement of 
the bronchial glands is very common in whooping-cough and has been 
thought to cause the disease. It may sometimes be sufficient to produce 
dulness over the manubrium. During the spasm the radial pulse is small, 
the right heart engorged, and during and after the attack the cardiac action 
is very much disturbed. Serious damage may result, and possibly some 
of the cases of severe valvular disease in children who have had neither i 
rheumatism nor scarlet fever may be attributed to the terrible heart strain 
during a prolonged attack of whooping-cough. Koplik regards the swelling 
about the face and eyes as an important sign of the heart strain. Serious 
renal complications are very uncommon, but albumin sometimes and sugar 
frequently are found in the urine. An unusually marked leucocytosis 
appears early, chiefly of the lymphocytes (Meunier). 

Diagnosis. — So distinctive is the " whoop " of the disease that the 
diagnosis is very easy; but occasionally there are doubtful cases, particu- 
larly during epidemics, in which a series of expiratory coughs occurs with- 
out any inspiratory crow. 

Prognosis. — Taken with its complications, whooping-cough must be 
regarded as a very fatal affection. According to Dolan, it ranks third 
among the fatal diseases of children in England, where the death-rate per 
1,000,000 from this disease is 5,000 annually. The younger the infant 
the greater is the probability of serious complications. The deaths are 
chiefly among children of the poor and among delicate infants. 

Treatment. — Parents should be warned of the serious nature of 
whooping-cough, the gravity of which is scarcely appreciated by the pub- 
lic. Particular care should be taken that children suspected of the disease 
are not sent to the public schools or exposed in any way so that other chil- 
dren can become contaminated. There is more reprehensible neglect in 
connection with this than with any other disease. The patient should be 
isolated, and if the paroxysms are at all severe, at rest in bed. Fresh air, 



INFLUENZA. 



95 



night and day, is a most essential element in the treatment of the disease. 
The medicinal treatment of whooping-cough is most unsatisfactory. In 
the catarrhal stage when there is fever the child should be in bed and a 
saline fever mixture administered. If the cough is distressing, ipecacuanha 
wine and paregoric may be given. For the paroxysmal stage a suspiciously 
long list of remedies has been recommended, twenty-two in one popular 
text-book on therapeutics. If the disease is due, as seems probable, to a 
germ growing upon and irritating the bronchial mucosa, a germicidal plan 
of treatment seems highly rational, and persistent attempts should be made 
to discover a suitable remedy. Quinine is one of the best drugs. One 
sixth of a grain may be given three times a day for each month of age, 
and 1-| grain for each year in children under five years. Eesorcin 
in a 1-per-cent solution, swabbed frequently on the throat; 2 or 3 grains 
of iodoform to an ounce of starch powder; a spray of carbolic acid 
— have all been warmly recommended. J. Lewis Smith advises the use of 
the steam atomizer with a solution of carbolic acid, chlorate of potassium, 
and bromide of potassium in glycerin. Bromoform, in doses of 1 to 5 
minims suspended in syrup, has been warmly recommended of late. Jacobi 
regards belladonna as the most satisfactory remedy. He gives it in full 
doses, as much as one sixth of a grain of the extract to a child of six or 
eight months three times a day. It should be given in sufficient doses to 
produce the cutaneous flush. Good results have been obtained by the use 
of antipyrin or a combination of it with bromine (Kerley.) 

After the severity of the attack has passed and convalescence has 
begun, the child should be watched with the greatest care. It is just at 
this period that the fatal broncho-pneumonias are apt to develop. The 
cough sometimes persists for months and the child remains weak and deli- 
cate. Change of air should be tried. Such a patient should be fed with 
care, and given tonics and cod-liver oil. 

XII. INFLUENZA (La Grippe). 

Definition. — A pandemic disease, appearing at irregular intervals, 
characterized by extraordinary rapidity of extension and the large number 
of people attacked. Following the pandemic there are, as a rule, for sev- 
eral years endemic or epidemic outbreaks in different regions. Clinically, 
the disease has protean aspects, but with a special tendency to at I nek the 
respiratory mucous membranes. 

History. — Great pandemics have been recognized since the sixteenth 
century. There have been four with their succeeding epidemics during 
the present century— 1830-'33, 183G-'37, 1847-'48, and 1889-90. The 
last pandemic began, as others had done before, in sonic of the distant prov- 
inces of Eussia (hence the name Russian fever) in October, and by the 
beginning of November it had reached Moscow. By the middle of Novem- 
ber Berlin was attacked. By the middle of December it was in London, 
and by the end of the month it had invaded \Yw York, and was v 
distributed over the entire continent. Within a year it had visited nearly 
all parts of the earth. 



96 



SPECIFIC INFECTIOUS DISEASES. 



The duration of an epidemic in any one locality is from six to eight 
weeks. With the exception, perhaps, of dengue, there is no disease which 
attacks indiscriminately so large a proportion of the inhabitants. For- 
tunately, as in dengue, the rate of mortality is very low, but the last epi- 
demic taught us to recognize in influenza, particularly its sequels and com- 
plications, one of the most serious of all specific diseases. The opportunity 
for studying the disease in the last epidemic has thrown much light upon 
many problems. Among the most notable productions were the work of 
Pfeiff er in discovering the specific germ, the elaborate Berlin report by von 
Leyden and Senator, and the Local Government Board's report by Parsons. 
Leichtenstern's article in ISTothnageFs Handbuch is the most masterly and 
systematic consideration of the disease in the literature. 

Etiology. — What relation has the epidemic influenza to the ordinary 
influenza cold or catarrhal fever (commonly also called the grippe), which 
is constantly present in the community? Leichtenstern answers this ques- 
tion by making the following divisions: (1) Epidemic influenza vera, caused 
by Pfeiff er's bacillus; (2) endemic-epidemic influenza vera, which often 
develops for several years in succession after a pandemic, also caused by the 
same bacillus; (3) endemic influenza nostras, pseudo-influenza or catarrhal 
fever, commonly called the grippe, which is a special disease, still of un- 
known etiology, and which bears the same relation to the true influenza as 
cholera nostras does to Asiatic cholera. 

During the past ten years, since the great pandemic of 1889-90, there 
have been epidemics in different localities, varying in extent and intensity. 

The disease is highly contagious; it spreads with remarkable rapidity, 
which, however, is not greater than modern methods of conveyance. In 
the great pandemic of 1889-^90 some of the large prisons escaped entirely. 
The outbreak of epidemics is independent of all seasonal and meteorological 
conditions, though the worst have been in the colder seasons of the year. 
One attack does not necessarily protect from a subsequent one. A few 
persons appear not to be liable to the disease. 

Bacteriology.— In 1892 Pfeiff er isolated a bacillus from the nasal 
and bronchial secretions, which is recognized as the cause of the disease. 
It is a small, non-motile organism, which stains well in Loeffler's methylene 
blue, or in a dilute, pale-red solution of carbol-fuchsin in water. On cul- 
ture media it grows only in- the presence of haemoglobin. The bacilli are 
present in enormous numbers in the nasal and bronchial secretions of 
patients, in the latter almost in pure cultures. They persist often after 
the severe symptoms have subsided. 

The much-discussed question whether during the presence of an epi- 
demic human influenza attacks animals must be answered in the negative. 
In great pandemics of influenza the general rule holds good that other 
diseases do not prevail to the same extent. Anders has brought forward 
statistics to indicate that the outbreaks of malaria are very much dimin- 
ished during the prevalence of influenza. 

Symptoms. — The incubation period is " from one to four days; often- 
est three to four days." The onset is usually abrupt, with fever and its 
associated phenomena. 



INFLUENZA. 97 

Types of the Disease. — The manifestations are so extraordinarily 
complex that it is best to describe them under types of the disease. 

1. Respiratory. — The mucous membrane of the respiratory tract from 
the nose to the air-cells of the lungs may be regarded as the seat of election 
of the influenza bacilli. In the simple forms the disease sets in with coryza, 
and presents the features of an acute catarrhal fever, with perhaps rather 
more prostration and debility than is usual. In other cases the catarrhal 
symptoms persist, bronchitis develops, the fever continues, there is de- 
lirium and much prostration, and the picture may even be that of severe 
typhoid. The graver respiratory conditions are bronchitis, pleurisy, and 
pneumonia. The bronchitis has really- no special peculiarities. The sputum 
is supposed by many to be distinctive. Sometimes it is in extraordinary 
amounts, very thin, and containing purulent masses. Pfeiffer regards 
sputum of a greenish-yellow color and in coin-like lumps as almost char- 
acteristic of influenza. In other cases there may be a dark red, bloody 
sputum. One of the most distressing sequels of the influenza bronchitis 
is diffuse bronchiectasis, of which I have seen several instances. It 
occasionally happens that the bronchitis is of great intensity and reaches 
the finer tubes, so that the patient becomes cyanosed or even asphyxiated. 

Influenza pneumonia is one of the most serious manifestations, and may 
depend upon Pfeiffer's bacillus itself, or is the result of a mixed infection. 
The true influenza pneumonia is most commonly lobular or catarrhal, less 
often croupous. Much of the mortality of the disease depends upon the 
fatal character of this complication. The clinical course of the cases is 
often irregular and the symptoms are obscure or masked. 

Influenza pleurisy is more rare, but cases of primary involvement of the 
pleura are reported. It is very apt to lead to empyema. Pulmonary 
tuberculosis is usually much aggravated by an attack of influenza. 

2. Nervous Form. — Without any catarrhal symptoms there may be 
severe headache, pain in the back and joints, with profound prostration. 
Many remarkable nervous manifestations were noted during the last epi- 
demic. Among the more serious may be mentioned meningitis and en- 
cephalitis, the latter leading to hemiplegia or monoplegia. Abscess of the 
brain has followed in acute cases. All forms of neuritis are not uncom- 
mon, and in some cases are characterized by marked disturbance of motion 
and sensation. Judging from the accounts in the literature, almost every 
form of disease of the nervous system may follow influenza. 

To involvement of the nerves may be ascribed some of the common 
cardiac symptoms, such as persistent irregularity, tachycardia or brady- 
cardia, and attacks of angina pectoris. Among the most important of the 
nervous sequelae are depression of spirits, melancholia, and in some cases 
dementia. 

3. G astro-intestinal Form. — With the onset of the fever there may be 
nausea and vomiting, or the attack may set in with abdominal pain, profuse 
diarrhoea, and collapse. In some epidemics jaundice has been a common 
symptom. In a considerable number of the cases there is enlargemenl of 
the spleen, depending chiefly upon the intensity of the fever. 

4. Febrile Form. — The fever in influenza is very variable, bui li ie 



98 



SPECIFIC INFECTIOUS DISEASES. 



important to recognize that it may be the only manifestation of the dis- 
ease. It is sometimes markedly remittent, with chills; or in rare cases 
there is a protracted, continued fever of several weeks duration, which 
simulates typhoid closely (W. W. Johnston). 

While these are perhaps the most common forms with their complica- 
tions, there are many others, among which may he mentioned the follow- 
ing: Various renal affections have been noted. G-. Baumgarten has called 
attention to the frequency of nephritis in the recent epidemic. Orchitis 
has been also seen. Endocarditis and pericarditis, phlebitis and thrombosis 
of the various vessels are reported. Herpes is common. A diffuse erythema 
sometimes occurs, occasionally purpura, Catarrhal conjunctivitis is a fre- 
quent event. Iritis, and in rare instances optic neuritis, have been met 
with. Acute otitis media was a common complication. I have seen severe 
and persistent vertigo follow influenza, probably from involvement of the 
labyrinth. 

Since the late severe epidemics it has been the fashion to date various 
ailments or chronic ill-health from influenza, In many cases this is cor- 
rect. It is astonishing the number of people who have been crippled in 
health for years after an attack. 

Diagnosis. — During a pandemic the cases offer but slight difficulty. 
The profoundness of the prostration, out of all proportion to the intensity 
of the disease, is one of the most characteristic features. In the respiratory 
form the diagnosis may be made by the bacteriological examination of the 
sputum, a procedure which should be resorted to early in a suspected epi- 
demic. The differentiation, of the various forms has been already suffi- 
ciently considered. 

Treatment. — Isolation should be practised when possible, and old 
people should be guarded against all possible sources of infection. The 
secretions, nasal and bronchial, should be thoroughly disinfected. In every 
case the disease should be regarded as serious, and the patient should be 
confined to bed until the fever has completely disappeared. In this way 
alone can serious complications be avoided. From the outset the treatment 
should be supporting, and the patient should be carefully fed and well 
nursed. The bowels should be opened by a dose of calomel or a saline 
draught. At night 10 grains of Dover's powder may be given. At the 
onset a warm bath is sometimes grateful in relieving the pain in the back 
and limbs, but great care should be taken to have the bed well warmed, 
and the patient should be given after it a drink of hot lemonade. If the 
fever is high and there is delirium, small doses of antipyrin may be given 
and an ice-cap applied to the head. The medicinal antipyretics should be 
used with caution, as profound prostration sometimes develops in these 
cases. Too much stress should not be laid upon the mental features. De- 
lirium may be marked even with slight fever. In the cases with great car- 
diac weakness stimulants should be given freely, and during convalescence 
strychnia in full doses. 

The intense bronchitis, pneumonia, and other complications should 
receive their appropriate treatment. The convalescence requires careful 
management, and it may be weeks or months before the patient is restored 



DENGUE. 



99 



to full health. A good nutritious diet, change of air, and pleasant sur- 
roundings are essential. The depression of spirits following this disease 
is one of its most unpleasant and obstinate features. 

XIII. DENGUE. 

Definition. — An acute infectious disease of tropical and subtropical 
regions, characterized by febrile paroxysms, pains in the joints and mus- 
cles, an initial erythematous, and a terminal polymorphous eruption. 

It is known as break-bone fever from the atrocious character of the pain, 
and dandy fever from the stiff, dandified gait. The word dengue is sup- 
posed to be derived from a Spanish, or possibly Hindoostanee, equivalent of 
the word dandy. 

History and Geographical Distribution.— The disease was first 
recognized in 1779 in Cairo and in Java, where Brylon described the out- 
break in Batavia. The description by Benjamin Rush of the epidemic 
in Philadelphia in 1780 is one of the first, and one of the very best ac- 
counts of the disease. Between 1824 and 1828 it was prevalent at intervals 
in India and in the Southern States. S. H. Dickson gives a graphic de- 
scription of the disease as it appeared in Charleston in 1828. Since that 
date there have been four or five widespread epidemics in tropical coun- 
tries and on this continent along the Gulf States, the last in the summer 
of 1897. None of the recent epidemics have extended into the Northern 
States, but in 1888 it prevailed as far north as Virginia. 

Etiology. — The rapidity of diffusion and the pandemic character are 
the two most important features of dengue. There is no disease, not even 
influenza, which attacks so large a proportion of the population. In Galves- 
ton, in 1897, 20,000 people were attacked within two months. It appears 
to belong to the group of exanthematic fevers, and has their highly infec- 
tious characters. A micrococcus has been found in the blood of patients by 
McLaughlin, of Texas. 

As the disease is rarely fatal, no observations have been made upon its 
pathological anatomy. 

Symptoms. — The period of incubation is from three to five days, 
during which the patient feels well. The attack sets in suddenly with 
headache, chilly feelings, and intense aching pains in the joints and mus- 
cles. The temperature rises gradually, and may reach 106° or 107°. The 
pulse is rapid, and there are the other phenomena associated with acute 
fever — loss of appetite, coated tongue, slight nocturnal delirium, and con- 
centrated urine. The face has a suffused, bloated appearance, the eyea arc 
injected, and the visible mucous membranes are flushed. There is a con- 
gested, erythematous state of the skin. Rush's description of the pains is 
worth quoting, as in it the epithet break-bone occurs in the literature Tor 
the 'first time. "The pains which accompanied this fever were exquisitely 
severe in the head, back, and limbs. The pains in the head were sometimes 
in the back parts of it, and at other times they occupied only the eyeballs 
In some people the pains were so acute in their hacks and hips thai they 
could not lie in bed. In others, the pains affected the neck and amis, so 



Lei C. 



100 



SPECIFIC INFECTIOUS DISEASES. 



as to produce in one instance a difficulty of moving the fingers of the right 
hand. They all complained more or less of a soreness in the seats of these 
pains, particularly when they occupied the head and eyeballs. A few com- 
plained of their flesh being sore to the touch in every part of the body. 
From these circumstances the disease was sometimes believed to be a rheu- 
matism, but its more general name among all classes of people was the break- 
bone fever." The large and small joints are affected, sometimes in suc- 
cession, and become swollen, red, and painful. In some cases cutaneous hy- 
peresthesia has been noted. Haemorrhage from the mucous membranes was 
noted by Eush. Black vomit has also been described by several observers. 

The fever gradually reaches its maximum by the third or fourth day; 
the patient then enters upon the apyretic period, which may last from two 
to four days, and in which he feels prostrated and stiff. A second paroxysm 
of fever then occurs, and the pains return. In a large number of cases an 
eruption is common, which, judging from the description, has nothing 
distinctive, being sometimes macular, like that of measles, sometimes dif- 
fuse and scarlatiniform, or papular, or lichen-like. In other instances the 
rash has been described as urticarial, or even vesicular. Certain writers 
describe inflammation and hyperemia of the mucous membrane of the 
nose, mouth, and pharynx. Enlargement of the lymph-glands is not un- 
common, and may persist for weeks after the disappearance of the fever. 
Convalescence is often protracted, and there is a degree of mental and 
physical prostration out of all proportion to the severity of the primary 
attack. The pains in the joints or muscles, sometimes very local, may per- 
sist for weeks. Rush refers to the former, stating that a young lady after 
recovery said it should be called break-heart, not break-bone, fever. The 
average duration of a moderate attack is from seven to eight days. Dengue 
is very seldom fatal. Dickson saw three deaths in the Charleston epidemic. 

Complications are rare. Insomnia and occasionally delirium, resem- 
bling somewhat the alcoholic form, have been observed, and convulsions 
in children. A relapse may occur even as late as two weeks. 

The diagnosis of the disease, prevailing as it does in epidemic form 
and attacking all classes indiscriminately, rarely offers any special difficulty. 
Isolated cases might be mistaken at first for acute rheumatism. The im- 
portant question of the differentiation between yellow fever and dengue 
will be considered later. 

Treatment. — This is entirely symptomatic. Quinine is stated to be 
a prophylactic, but on insufficient grounds. Hydrotherapy may be em- 
ployed to reduce the fever. The salicylates or antipyrin may be tried for 
the pains, which usually, however, require opium. During convalescence 
iodide of potassium is recommended for the arthritic pains, and tonics are 
indicated. 

XIV. CEREBRO-SPINAL FEVER. 

Definition. — An infectious disease, occurring sporadically and in 
epidemics, caused by the diplococcus intracellularis, characterized by in- 
flammation of the cerebro-spinal meninges and a clinical course of great 
irregularity. 



CEREBROSPINAL FEVER. 



101 



The affection is also known by the names of malignant purpuric fever, 
petechial fever, and spotted fever. 

History. — Yieusseux first described a small outbreak in Geneva in 
1805. In 1806 L. Danielson and E. Mann (Medical and Agricultural 
Begister, Boston) gave an account of " a singular and very mortal disease 
which lately made its appearance in Medford, Mass/ 7 

The disease attracted much attention and was the subject of several 
very careful studies. The Massachusetts Medical Society, in 1809, ap- 
pointed James Jackson, Thomas Welch, and J. C. Warren to investigate it. 
Elisha North's little book (1811) gives a full account of the early epi- 
demics. Stille's monograph (1867) and the elaborate section in vol. i of 
Joseph Jones' works contain details of the later American outbreaks. 
Hirsch's Geographical Pathology, the appendix by Ormerod to his article 
in Allbutt's System, and better's comprehensive article in the Twentieth 
Century Practice, vol. xvi, give full details of the epidemics in different 
countries. Hirsch divides the outbreaks into four periods: From 1805 
to 1830, in which the disease was most prevalent throughout the United 
States; a second period, from 1837 to 1850, when the disease prevailed ex- 
tensively in France, and there were a few outbreaks in the United States; 
a third period, from 1854 to 1874, when there were outbreaks in Europe 
and several extensive epidemics in this country. During the civil war 
there were comparatively few cases of the disease. It prevailed extensively 
in the Ottawa Valley early in the seventies. In the fourth period, from 
1875 to the present time, the disease has broken out in a great many 
regions. During the past decade there have been localized outbreaks in 
many lands. In this country, during 1898-'99, it prevailed in mild form 
in 27 States. The outbreak in Boston has been described by Councilman. 
Mallory, and Wright, in Chicago by Class, and in Baltimore by the writer 
(Cavendish Lecture, Philadelphia Medical Journal, 1899). It is a rare 
disease in Great Britain. In Ireland there have been a few outbreaks, 
a mild one last year. 

Etiology. — Cerebrospinal fever occurs in epidemic and in sporadic 
forms. The epidemics are localized, occurring in certain regions, and are 
rarely very widespread. As a rule, country districts have been more 
afflicted than cities. The outbreaks have occurred most frequently in the 
winter and spring. The concentration of individuals, as of troops in largo 
barracks, seems to be a special factor, and epidemics on the Continent 
show how liable recruits and young soldiers are to the disease. In civil 
life children and young adults are most susceptible. Over-exertion, long- 
marches in the heat, depressing mental and bodily surroundings, and the 
misery and squalor of the large tenement houses in cities are predisposing 
causes. The disease seems not to be directly contagious, and is probably 
not transmitted by clothing or -the excretions. It is very rare to have 
more than one or two cases in a house, and in a city epidemic the distribu- 
tion of the cases is very irregular. Councilman has found five instances 
in which the same individual is reported to have had the disease twice. 

Sporadic cerebrospinal fever occurs in all the larger cities and in 
country districts of this continent. The disease lingers in a city indefinitely 



102 



SPECIFIC INFECTIOUS DISEASES. 



after an outbreak, and in Boston, Philadelphia, and Baltimore a moderate 
number of cases occur every year. It seems probable that the form of 
meningitis known as the posterior basic is of this nature, and Still at the 
Great Ormond Street Hospital and Hunter and Nuthall have isolated an 
organism similar to the diplococcus intracellularis. The clinical and ana- 
tomical features of this form are very fully discussed by Barlow and Lees 
in Allbutt's System. It is very desirable that these sporadic forms of 
meningitis, both in adults and in children, should be carefully studied 
by the newer methods to determine the relative incidence of the forms 
due to the pneumoeoccus and to the diplococcus intracellularis. The 
clinical features, too, of the sporadic forms present interesting variations 
which are worthy of additional study. 

Bacteriology. — In 1887 Weichselbaum described an organism, the 
Diplococcus intracellularis meningitidis, which was probably the same as 
one previously found by Leichtenstern. In the tissues the organism is 
almost constantly within the polynuclear leucocytes. In cultures it has 
well-characterized features, and is distinguishable from the pneumoeoccus. 
Since Weichselbaum's observations this organism has been met with in 
all carefully studied epidemics of the disease. In the Boston outbreak, 
in 35 of the cases on which post-mortem examinations were made, the 
diplococci were demonstrated in all but 4, in one of which they had pre- 
viously been found in fluid withdrawn by spinal puncture. The other 
3 cases were chronic. Since the appearance of the last edition (1898) we 
have had an opportunity of observing a small outbreak, and we have 
found the diplococcus intracellularis in all of the acute cases. The recent 
studies, too, in Paris and Germany have all been confirmatory of the 
constant association of this organism with the disease. 

Morbid Anatomy. — In malignant cases there may be no characteris- 
tic changes, the brain and spinal cord showing only extreme congestion, 
which was the lesion described by Yieusseux. In a majority of the acutely 
fatal cases death occurs within the first week. There is intense injection of 
the pia-arachnoid. The exudate is usually fibrino-purulent, most marked 
at the base of the brain, where the meninges may be greatly thickened and 
plastered over with it. On the cortex there may be much lymph along 
the larger fissures and in the sulci; sometimes the entire cortex is covered 
with a th^ck, purulent exudate. It deserves to be recorded that Danielson 
and Mann made five autopsies and were the first to describe " a fluid resem- 
bling pus between the dura and pia mater/' The cord is always involved 
with the brain. The exudate is more abundant on the posterior surface, 
and involves, as a rule, the dorsal and lumbar regions more than the cervical 
portion. 

In the more chronic cases there is general thickening of the meninges 
and scattered yellow patches mark where the exudate has been. The ven- 
tricles in the acute cases are dilated and contain a turbid fluid, or in the 
posterior cornua pure pus. In the chronic cases the dilatation may be very 
great. The brain substance is usually a little softer than normal and has 
a pinkish tinge; foci of haemorrhage and of encephalitis may be found. 
The cranial nerves are usually involved, particularly the second, fifth, sev- 



CEREBRO-SPINAL FEVER. 



103 



enth, and eighth. The spinal nerve roots are also found imbedded in the 
exudate. 

Microscopically, the exudate consists largely of polynuclear leucocytes 
closely packed in a fibrinous material. Flexner and Barker describe larger 
cells, from two to eight times the diameter of a leucocyte. The lesions in 
the tissue of the brain and cord, according to Councilman, are more marked 
in this than in other forms. They consist chiefly in infiltration of the 
tissue with pus cells, which extend downward in the perivascular spaces. In 
some instances there are foci of purulent infiltration and haemorrhage. 
The neuroglia cells are swollen, with large, clear, and vesicular nuclei. 
The ganglion cells show less marked changes. Diplococci are found in 
variable numbers in the exudate, being more numerous in the brain than in 
the cord. 

Lesions in Other Parts. — In one of the Boston cases, examination 
of the nasal secretion during life showed diplococci, and in this instance 
there was found post mortem a purulent infiltration of the mucous mem-' 
brane. In two other cases this membrane was normal. 

Lungs. — Pneumonia and pleurisy have been described in the disease. 
Councilman reports that in the recent epidemic in 13 cases there was con- 
gestion with oedema, in 7 broncho-pneumonia, in 2 characteristic croupous 
pneumonia with pneumococci; in 8 pneumonia due to the diplococcus intra- 
cellularis was present. 

Spleen. — The organ varies a good deal in size. In only three of the 
Boston fatal cases was it found much enlarged. The liver is rarely abnormal. 
Acute nephritis is sometimes present. The intestines show sometimes swell- 
ing of the follicles, but this was not present in any of the Boston cases. 

Symptoms. — Cases differ remarkably in their characters. Many dif- 
ferent forms have been described. These are perhaps best grouped into 
three classes: 

1. Malignant Form. — This fulminant or apoplectic type is found with 
variable frequency in epidemics. It may occur sporadically. The onset 
is sudden, usually with violent chills, headache, somnolence, spasms in the 
muscles, great depression, moderate elevation of temperature, and feeble 
pulse, which may fall to fifty or sixty in the minute. Usually a purpuric 
rash develops. In a Philadelphia case, in 1888, a young girl, apparently 
quite well, died within twenty hours of this form. There are rases on 
record in which death has occurred within a shorter time. Stille* tells of 
a child of five years, in whom death occurred after an illness of ten hours; 
and refers to a case reported by Gordon, in which the entire duration of 
the illness was only five hours. Two of Vieusseux's eases died within 
twenty-four hours. 

2. Ordinary Form. — The stage of incubation is not known. The dis- 
ease usually sets in suddenly. There may be premonitory symptoms: 
headache, pains in the back, and loss of appetite. More commonly, the 
onset is with headache, severe chill, and vomiting. The temperature rises 
to 101° or 102°. The pnlse is full and strong. An early and important 
symptom is a painfr.l stiffness of the muscles of the neck. The headache 
increases, and there are photophobia and great sensitiveness to noi - 

7 



104 



SPECIFIC INFECTIOUS DISEASES. 



Children become very irritable and restless. In severe cases the contrac- 
tion of the muscles of the neck sets in early, the head is drawn back, and,, 
when the muscles of the back are also involved, there is orthotonos, which 
is more common than opisthotonos. The pains in the back and in the 
limbs may be very severe. The motor symptoms are most characteristic. 
Tremor of the muscles may be present, with tonic or clonic spasms in the 
arms or legs. Eigidity of the muscles of the back or neck is very com- 
mon, and the patient lies with the body stiff and the head drawn so far 
back that the occiput may be between the shoulder-blades. Except in 
early childhood convulsions are not common. Strabismus is a frequent 
and important symptom. Spasm of the muscles of the face may also 
occur. Cases have been described in which the general rigidity and stiff- 
ness was such that the body could be moved like a statue. Paralysis of 
the trunk muscles is rare, but paralysis of the muscles of the eye and the 
face is not uncommon. 

Of sensory symptoms, headache is the most dominant and persists from 
the outset. It is chiefly in the back of the head, and the pain extends 
into the neck and back. There may be great sensitiveness along the spine^ 
and in many cases there is marked hyperesthesia. 

The psychical symptoms are pronounced. Delirium occurs at the onset,, 
occasionally of a furious and maniacal kind. The patient may display at 
the start marked erotic symptoms. The delirium gives place in a few days- 
to stupor, which, as the effusion increases, deepens to coma. 

The temperature is irregular and variable. Remissions occur frequently,, 
and there is no uniform or typical curve during the disease. In some in- 
stances there has been little or no fever. In others the temperature may 
reach 105° or 106°, or, before death, 108°. The pulse may be very rapid 
in children; in adults it is at first usually full and strong. In some cases- 
it is remarkably slow, and may not be more than fifty or sixty in the minute. 
Sighing respirations and Cheyne-Stokes breathing are met with in some 
instances. Unless there is pneumonia the respirations are not often in- 
creased in frequency. 

The cutaneous symptoms of the disease are important. Herpes occurs- 
with even greater frequency than in pneumonia or in intermittent fever. 
The petechial rash, which has given the name spotted fever to the dis- 
ease, is very variable. Stille states that of 98 cases in the Philadel- 
phia Hospital, no eruption was observed in 37. In the Montreal 
cases petechias and purple spots were common. They appear to have been 
more frequent in the epidemics on this continent than in Europe. The 
petechia? may be numerous and cover the entire skin. An erythema or 
dusky mottling may be present. In some instances there have been rose- 
colored hypereemic spots like the typhoid rash. Urticaria or erythema no- 
dosum, ecthyma, pemphigus, arid in rare instances gangrene of the skin 
have been noted. 

Leucocytosis is an early and constant feature, and ranges from 25,000 
to 40,000 per cubic millimetre. It persists even in the most protracted 
cases. In one of our cases the diplococcus intracellularis was isolated 
from the blood during life. 



CEREBRO-SPINAL FEVER. 



105 



As already stated, vomiting may be a special feature at the onset; but, 
as a rule, it gradually subsides. In some instances, however, it persists 
and becomes the most serious and distressing of the symptoms. Diarrhoea 
is not common. The bowels are usually confined. The abdomen is not 
tender. In the acute form the spleen is usually enlarged. 

The urine is sometimes albuminous and the quantity may be increased. 
Glycosuria has been noted in some instances, and in the malignant types 
hematuria. 

The course of the disease is extremely variable. Hirsch rightly states 
that it may range between a few hours and several months. More than 
half of the deaths occur within the first five days. In favorable cases, 
after the symptoms have persisted for five or six days, improvement is in- 
dicated by a lessening of the spasm, reduction of the fever, and a return 
of the intelligence. A sudden fall in the temperature is of bad omen. Con- 
valescence is extremely tedious, and may be interrupted by complications 
and sequelae to be noted. 

3. Anomalous Forms. 

(a) Abortive Type. — The attack sets in with great severity, but in a 
day or two the symptoms subside and convalescence is rapid. Striimpell 
would distinguish between this abortive variety, which begins with such 
intensity, and the mild ambulant cases described by certain writers. He 
reports a case in which the meningeal symptoms set in with the greatest 
intensity and persisted for four days, the temperature rising to 105.6° F. 
On the fifth day the patient entered upon a rapid and satisfactory con- 
valescence. In the mild cases, as distinguished from the abortive, the pa- 
tients complain of headache, nausea, sensations of discomfort in the back 
and limbs, and stiffness in the neck. There is little or no fever, and only 
moderate vomiting. These cases could be recognized only during the 
prevalence of an epidemic. 

(b) An Intermittent Type has been observed in many epidemics, and is 
recognized by von Ziemssen and Stille. It is characterized by exacerba- 
tions of fever, which may recur daily or every second day, or follow a curve 
of an intermittent or remittent character. The pyrexia resembles thai of 
pyaemia rather than malaria. 

(c) Chronic Form. — Heubner states that this is a relatively Erequenl 
form, though it does not seem to be recognized by many writers on the 
subject. An attack may be protracted for from two to five or ever sis 
months, and may cause the most intense marasmus. It is characterized by 
a series of recurrences of the fever, and may present the most complex 
symptomatology. It is not improbable that these protracted eases depend 
upon chronic hydrocephalus or abscesses of the brain. This form differs 
distinctly from the intermittent type. Three eases in our recenl series 
were of this chronic form; in one patient the disease persisted for ninety 
days. 

Complications. — Pleurisy, pericarditis, and parotitis are not un- 
common. 

Pneumonia is described as frequent in certain out breaks. Innnennann 
found, during the Erlangen epidemic, many instances of the combination 
of pneumonia with meningitis, but it does not seem possible t<> determine 



106 



SPECIFIC INFECTIOUS DISEASES. 



whether, in such cases, pneumonia is the primary disease and the meningitis 
secondary, or vice versa. The frequency with which inflammation of the 
meninges of the brain complicates pneumonia is well known. Council- 
man suggests that the pneumonia of the disease is not the true croupous 
form, but due to the diplococcus meningitidis. This was found in eight 
of the Boston cases, and in one it was so extensive that it could have been 
mistaken for the ordinary croupous pneumonia. Arthritis has been the 
most frequent complication in certain epidemics. Many joints are affected 
simultaneously, and there are swelling, pain, and exudation, sometimes 
serous, sometimes purulent. This was first observed by James Jackson, Sr., 
in the epidemic which he described. Enteritis is rare. 

Headache may persist for months or years after an attack. Chronic 
hydrocephalus develops in certain instances in children. The symptoms 
of this are " paroxysms of severe headache, pains in the neck and extremi- 
ties, vomiting, loss of consciousness, convulsions, and involuntary discharges 
of faeces and urine " (von Ziemssen). Von Ziemssen regards chronic hydro- 
cephalus as by no means a rare sequela. Mental feebleness and aphasia 
have occasionally been noted. 

Paralysis of individual cranial nerves or of the lower extremities may 
persist for some time. In some of these cases there may be peripheral 
neuritis, as Mills suggested. 

Special Senses. — Eye. — These are due to three causes: First, neuritis 
following involvement of the nerve in the exudation at the base. This may 
affect the third nerve or the optic nerves, leading to acute papillitis,' which 
was found in 6 out of 40 cases examined by Randolph. Secondly, the 
inflammation may extend directly into the eye along the pia-arachnoid of 
the optic nerve, causing purulent choroido-iritis or even keratitis. Thirdly, 
a neuritis of the fifth nerve may be followed by keratitis and purulent 
conjunctivitis. 

Ear. — Deafness very often follows inflammation of the labyrinth. Otitis 
media, with mastoiditis, may develop from direct extension. In 64 cases 
of meningitis which recovered, Moos found that 55 per cent were deaf. He 
suggests that the abortive form of the disease may be responsible for many 
cases of early acquired deafness. In children this not infrequently leads 
to deaf-mutism. Von Ziemssen states that in the deaf and dumb institutions 
of Bamberg and Nuremberg, in 1874, a majority of the pupils had become 
deaf from epidemic cerebro-spinal meningitis. 

Nose. — Coryza is not infrequent early in the disease, and Striimpell says 
that in many of his cases nasal catarrh preceded the meningitis. He sug- 
gests that the latter may be caused by infection from the nose. Certainly 
the nasal secretion appears frequently to contain the diplococei — in 18 cases 
examined by Scherrer, and in 10 out of 15 of the Boston cases. 

Diagnosis. — Much has been done of late to enable the practitioner 
to recognize definitely the existence of meningitis and of the various 
forms. 

(a) The fever, headache, delirium, retraction of the neck, tremor, and 
rigidity of the muscles are most important signs. As already mentioned, in 
the meningitis of cerebro-spinal fever the spinal symptoms are very much 



CEREBRO-S PINAL FEVER. 107 

more marked than in the other forms. One has constantly to hear in 
mind that certain cases of typhoid fever and of pneumonia closely simulate 
cerebro-spinal meningitis. Long ago Stokes made the wise observation 
that " there is no single nervous symptom which may not and does not 
occur independently of any appreciable lesion of the brain, nerves, or 
spinal cord." 

(b) Among the special diagnostic features may be mentioned: 

Kemig's Sign. — When the thigh is flexed at right angles to the abdo- 
men, the leg can be extended upon the thigh nearly in a straight line. 
If meningitis be present, strong contractures of the flexors prevent the 
full extension of the leg on the, thigh. This is a valuable sign, and has 
been present in all of our recent cases. 

Lumbar Puncture. — The procedure is quite harmless, and in a majority 
of the cases can be done without general anaesthesia, with the aid of a 
local freezing mixture. As a rule, it is best in children to give a whiff 
or two of chloroform. The patient is turned on the right side with the 
back bowed, the knees drawn up, and the left shoulder forward. As a 
rule, there is no difficulty in finding the spinal processes, and with the 
thumb or index finger of the left hand as a guide, a small aspirator needle 
or that of the antitoxin syringe is inserted to one side of the median line 
and thrust deeply into the third interspace in an upward and inward 
direction. At a variable distance, according to the age and musculature, 
the needle enters the spinal cord, — about two and a half centimetres in 
infants and from four to six centimetres in adults. 

The fluid runs, as a rule, drop by drop, and when meningitis is present 
it is usually turbid, sometimes purulent, occasionally bloody. Meningitis 
may be present with a clear fluid. Cover-glass preparations should be 
made and studied, and the character of the organisms carefully noted. 
The cover-slip preparations may give the diagnosis at once. In acute 
cases of cerebro-spinal fever the organisms may be present in large num- 
bers. There is rarely any difficulty in determining between the pneui no- 
coccus and the diplococcus intracellularis. Should the fluid be sterile 
and tuberculosis suspected, a guinea-pig may be inoculated. 

Cyto-diagnosis. — Eecent French writers claim that in tuberculous men- 
ingitis the exudate obtained by lumbar puncture contains only lymphocytes, 
while in the pneumococcus meningitis and in cerebro-spinal fever the poly- 
nuclear leucocytes predominate. They claim too that the meninges are 
impermeable to potassium iodide in cerebro-spinal fever, and the iodine 
can not be detected in the fluid obtained by lumbar puncture; while in tu- 
berculous meningitis it is present. In recent cases we have not beeD able 
to confirm either of these observations. 

Prognosis. — Ilirsch states that the mortality lias ranged in various 
epidemics from 20 to 75 per cent. In children the death-rate is much 
higher than in adults. Cases with deep coma, repeated convulsions, and 
high fever rarely recover. The outlook in the protracted eases is not good, 
though Ilcubner gives an instance of a lad of seven, who was ill from the 
end of February until the end of June, with repeated recurrences, v, 
worn to a skeleton, and yet completely recovered. 



108 



SPECIFIC INFECTIOUS DISEASES. 



Treatment. — The high rate of mortality which has existed in most 
epidemics indicates the futility of the various therapeutical agents which 
have been t recommended. When we consider the nature of the local dis- 
ease and the fact that, so far as we know, simple and tuberculous cerebro- 
spinal meningitis are invariably fatal, we may wonder rather that recovery 
follows in any well-developed case. 

In strong robust patients the local abstraction of blood by wet cups 
on the nape of the neck relieves the pain. General bloodletting is rarely 
indicated. Cold to the head and spine, which was used in the first epi- 
demics by New England physicians, is of great service. A bladder of ice 
to the head, or an ice-cap, and the spinal ice-bag may be continuously em- 
ployed. The latter is very beneficial. Hydrotherapy should be systematic- 
ally used, in the form of the tub bath, at 98°, as recommended by Aufrecht. 
Netter speaks highly of its good effects, and we have also seen it do good. 
It may be given every third hour. If any counter-irritation is thought 
necessary, the skin of the back of the neck may be lightly touched with 
the Paquelin thermocautery. Blisters, which have been used so much, are 
of doubtful benefit. The lumbar puncture seems helpful in cases with 
coma or convulsions, and in any case it does no harm. Of internal reme- 
dies opium may be given freely, best as morphia hypodermically. Yon 
Ziemssen advises the hypodermic injection of morphia, from one third 
to one half grain in adults. Mercury has no special influence on menin- 
geal inflammation. Iodide of potassium is warmly recommended by some 
writers. Quinine in large doses, ergot, belladonna and Calabar bean have 
had advocates. Bromide of potassium may be employed in the milder 
cases, but it is not so useful as morphia to control the spasms. 

The diet should be nutritious, consisting of milk and strong broths 
while the fever persists. Many cases are very difficult to feed, and Heubner 
recommends forced alimentation with the stomach-tube. The cases seem 
to bear stimulants well, and whisky or brandy may be given freely when 
there are signs of a failing heart. 

XV. LOBAR PNEUMONIA. 

{Croupous or Fibrinous Pneumonia ; Pneumonitis; Lung Fever.) 

Definition. — An infectious disease characterized by inflammation of 
the lungs, toxaemia of varying intensity, and a fever that terminates ab- 
ruptly by crisis. Secondary infective processes are common. The micro- 
coccus lanceolatus of Fraenkel is present in a large proportion of the cases. 

Incidence. — The most widespread and fatal of all acute diseases, 
pneumonia is now the " Captain of the Men of Death," to use the phrase 
applied by John Bunyan to consumption. In the United States during 
the census year 1890 there died of it 76,496, a death-rate per 100,000 
of population of 186.94. In Chicago during the past ten years it has 
gradually replaced consumption as the principal cause of death, which 
A. R. Reynolds attributes to the predisposing influence of influenza. In 



LOBAR PNEUMONIA. 



109 



the last decade the death-rate was 18.03 per 10,000 of population, against 
12.36 per 10,000 in the previous decade. There has been a marked in- 
crease in the disease in Baltimore, and Folsom has brought forward evi- 
dence to show that there has been a progressive increase in the death-rate 
from pneumonia in the State of Massachusetts. The admission of pneu- 
monia cases to hospitals during the past few years has in some places almost 
doubled. 

Etiology. — Age. — To the sixth year the predisposition to pneumonia 
is marked; it diminishes to the fifteenth year, but then for each subsequent 
decade it increases. For children Holt's statistics of 500 cases give: First 
year, 15 per cent; from the second to the sixth year, 62 per cent; from the 
seventh to the eleventh year, 21 per cent; from the twelfth to the four- 
teenth year, 2 per cent. Lobar pneumonia has been met with in the new- 
born. The relation to age is well shown in the last Census Eeport. The 
death-rate in persons from fifteen to forty-five years was 100.05 per 100,000 
of population; from forty-five to sixty-five years it was 263.12; and in per- 
sons sixty-five years of age and over it was 733.77. Pneumonia may well 
be called the friend of the aged. Taken off by it in an acute, short, not 
often painful illness, the old man escapes those " cold gradations of decay " 
so distressing to himself and to his friends. 

Sex. — Males are more frequently affected than females. The Census 
Eeport for 1890 gives 42,739 males against 33,757 females. 

Race. — In this country pneumonia is more fatal in the colored race than 
among the whites, the death-rate being 278.97 against 182.21. 

Social Condition. — The disease is more common in the cities. The 
census figures give 234.07 deaths per 100,000 of population for the cities 
against 141.09 for rural districts. Individuals who are much exposed to 
hardship and cold are particularly liable to the disease. New-comers and 
immigrants are stated to be less susceptible than native inhabitants. 

Personal Condition. — Debilitating causes of all sorts render individuals 
more susceptible. Alcoholism is perhaps the most potent predisposing 
factor. Eobust, healthy men are, however, often attacked. 

Previous Attach. — No other acute disease recurs in the same individual 
with such frequency. Instances are on record of individuals who have had 
ten or more attacks. The percentage of recurrences has been placed as 
high as 50. Netter gives it as 31, and he has collected the statistics 
of eleven observers who place the percentage at 26.8. Among the 
highest figures for recurrences are those of Benjamin Rush, 38, and 
Andral, 16. 

Trauma — Contusion-pneumonia. — Pneumonia may follow directly upon 
injury, particularly of the chest, without necessarily any lesion of the 
lung. Litten gives 4.4 per cent, Stern 2.8 per cent. There has been but 
one well-marked case in twelve years at the Johns Hopkins Hospital. 
Stern describes three clinical varieties: first, the ordinary Lobar pneu- 
monia following a contusion of the chesi wall; second, atypical cases, 
with slight fever and not very characteristic physical signs; third, i 
with the physical signs and features of broncho -pneumonia. The lasi 
two varieties have a favorable prognosis. According to Ballard, workers in 



110 



SPECIFIC INFECTIOUS DISEASES. 



certain phosphate factories, where they breathe a very dusty atmosphere, 
are particularly prone to pneumonia. 

Cold has been for years regarded as an important etiological factor. 
The frequent occurrence of an initial chill has been one reason for this 
widespread belief. As to the close association of pneumonia with exposure 
there can be no question. We see the disease occur either promptly after 
a wetting or a chilling due to some unusual exposure, or come on after 
an ordinary catarrh of one or two days' duration. Cold is now regarded 
simply as a factor in lowering the resistance of the bronchial and pul- 
monary tissues. 

Climate and Season. — Climate does not appear to have very much in- 
fluence, as pneumonia prevails equally in hot and cold countries. It is 
stated to be more prevalent in the Southern than in the Northern States, 
but an examination of the last Census Eeport shows that there is very little 
difference in the various State groups. 

Much more important is the influence of season. Statistics are almost 
unanimous in placing the highest incidence of the disease in the winter 
and spring months. In Montreal January, the coldest month of the year, 
but with steady temperature, has usually a comparatively low death-rate 
from pneumonia. The large statistics of Seitz from Munich and of Seibert 
of New York give the highest percentage in February and March. 

Bacteriology of Acute Lobar Pneumonia. — (a) Micrococcus 
lanceolatus, Pneumococcus or Diplococcus pneumonia} of Fraenkel and 
Weichselbaum. — In September, 1880, Sternberg inoculated rabbits with his 
own saliva and isolated a micrococcus. The publication was not made until 
April 30, 1881. Pasteur discovered the same organism in the saliva of a 
child dead of hydrophobia in December, 1880, and the priority of the 
discovery belongs to him, as his publication is dated January 18, 1881. 
There was, however, no suspicion that this organism was concerned in 
the etiology of lobar pneumonia, and it was not really until April, 1881, 
that A. Fraenkel determined that the organism found by Sternberg and 
Pasteur in the saliva, and known as the coccus of sputum septicaemia, was 
the most frequent organism in acute pneumonia. At first there was a 
good deal of confusion between this and the organism described by Fried- 
lander, November, 1883, and which is now known as the pneumo-bacillus. 
FVaenkel and Weichselbaum, in 1886, demonstrated the diplococcus in 
most cases of croupous pneumonia, and later studies have made it 
probable that this organism is the sole cause of genuine acute lobar 
pneumonia. 

The organism is a somewhat elliptical, lance-shaped coccus, usually 
occurring in pairs; hence the term diplococcus. It is readily demon- 
strated in cover-glass preparations with the usual dyes and by the Gram 
method. About the organism in the sputum a capsule can always be 
demonstrated. Its cultural and biological properties present many vari- 
ations, for a consideration of which the student is referred to the text- 
books on bacteriology. Scarcely any peculiarity is constant. A large 
number of varieties have been cultivated. Its kinship to streptococcus 
pyogenes is regarded by many as very close. 



LOBAR PNEUMONIA. 



Ill 



Distribution in the Body. — In' the bronchial secretions and in the af- 
fected lung it is readily demonstrated in cover-slips, and in the latter in 
sections. The organism was isolated from the blood by Cole in 9 of 64 
cases at my clinic in the session of 1900-1901. 

Micrococcus lanceolatus under other Conditions. — In this connection a 
very important point is the presence of the virulent organism in the mouth 
and bronchial secretions of healthy individuals — 20 per cent, according 
to better's observations. It occurs also in a non-virulent state, and may 
be regarded as a regular inhabitant of the mouth and pharynx. 

In other Diseases. — The organism is very widely distributed, and is 
found in many other conditions besides croupous pneumonia. It is a 
common cause of primary and secondary broncho-pneumonias, and has 
been found also in pleurisy, pericarditis, meningitis, peritonitis, acute 
synovitis, otitis, endocarditis, etc. 

An acute general infection with micrococcus lanceolatus without local- 
ized foci may prove rapidly fatal, constituting a pneumococcus septicaemia 
comparable to the typhoid septicaemia already described. Townsend has 
reported a remarkable case of a girl aged six, who had pain in the abdo- 
men, vomiting, and a temperature of 104.2°. There was no exudate in the 
throat. Twenty-four hours from the beginning of the symptoms she had 
a convulsion and died six hours later. There was found a general infection 
with the pneumococcus, which occurred in the blood, lungs, spleen, and 
kidneys. In Flexner's study of terminal infections micrococcus lanceo- 
latus was found four times in acute peritonitis, eleven times in acute peri- 
carditis, five times in acute endocarditis, three times in acute pleurisy, 
and three times in acute meningitis. 

Outside the body the organism has been found in the dust and sweepings 
of rooms. 

(b) Bacillus pneumoniae of Friedldnder. — This is a larger organism than 
the pneumococcus, and appears in the form of plump, short rods. It also 
shows a capsule, but presents marked biological and cultural differences 
from Fraenkel's pneumococcus. It occurred in 9 of Weichselbaum's 129 
cases. It may cause broncho-pneumonia and other affections, but probably 
is not a cause of genuine lobar pneumonia. 

(c) Other Organisms. — Various bacteria may be associated with the 
pneumococcus in lobar pneumonia, the most common of these being strep- 
tococcus pyogenes, the pyogenic staphylococci, and Friedlander's pneumo- 
bacillus; but while these latter may cause broncho-pneumonias, they have 
not been satisfactorily demonstrated to be other than secondary invaders 
in lobar pneumonia. Likewise the pneumonias caused by bacillus typho- 
sus, bacillus diphtheria?, and the influenza bacillus are not to be identified 
with true lobar pneumonia. 

Clinically, the infectious nature of pneumonia was recognized long be- 
fore we knew anything of the pneumococcus. Among the Tea tares which 
favored this view were the following: First, the disease is similar to other 
infections in its mode of outbreak. It may occur in endemic form, local- 
ized in certain houses, in barracks, jails, and schools. As many as ten 
occupants of one house have been attacked, and in hospital practice it is 



112 



SPECIFIC INFECTIOUS DISEASES. 



not infrequent to have 2 or 3 cases admitted from the same house. I have 
seen three members of a family consecutively attacked with a most malig- 
nant type of pneumonia. Among the more remarkable endemic outbreaks 
is that reported by W. B. Bodman, of Frankfort, Ky. In a prison with 
a population of 735 there occurred in one year 118 cases of pneumonia 
with 25 deaths. At the penitentiary at Amberg during a period of five 
months there were 161 cases, with a mortality above 28 per cent. The 
disease may assume epidemic proportions. In the Middlesborough epi- 
demic, so carefully studied by Ballard, there were 682 persons attacked 
with a mortality of 21 per cent. During some years pneumonia is so preva- 
lent that it is practically pandemic. Direct contagion is suggested by the 
fact that a patient in the next bed to a pneumonia case may take the dis- 
ease, or 2 or 3 cases may follow in rapid succession in a ward. It is very 
exceptional, however, for nurses or doctors to be attacked. 

Secondly, the clinical course of the disease is that of an acute infection. 
It is the very type of a self-limited disease, running a definite cycle in a 
way seen only in infectious disorders. 

Thirdly, as in other acute infections, the constitutional symptoms may 
bear no proportion whatever to the severity of the local lesion. As is well 
known, a patient may have a very small apex pneumonia which does not 
seriously impair the breathing capacity, but which may be accompanied 
with the most intense toxic features. 

Immunity and Serum Therapy. — The pneumococcus does not produce 
in artificial cultures any strong, soluble toxin analogous to the diphtheria 
toxin or the tetanus toxin, but its poison is contained within the bac- 
terial cells, from which it may be extracted in various ways, or it may 
be set free from the dead or degenerated cocci. The possibility that the 
pneumococcus may secrete a soluble toxin in the infected human or animal 
body may be admitted, but of this there is no conclusive demonstration. 
By the use of living or dead pneumococci or their extracts, animals may 
be vaccinated against this organism, so that their blood-serum is capable 
of protecting susceptible animals against many times the minimal fatal 
dose of the virulent pneumococcus. Strong protective serum has thus been 
obtained from rabbits, horses, asses, cows, and other animals subjected 
to repeated inoculations with dead and living cultures of the pneumococcus. 
This specific serum is not, as was at first supposed by the Klemperers, an 
antitoxic serum. The exact mode of its action has not been satisfactorily 
determined. It is considered by A. and M. Wassermann to belong to the 
class of bactericidal or bacteriolytic sera, like the anti-cholera and the 
anti-typhoid sera, whereas Metschnikoff and his school believe that it acts 
by stimulating the leucocytes to ingest and destroy the pneumococci. M. 
Wassermann finds that the specific protective substances are formed in 
the bone-marrow, and thence distributed to the blood. There is evidence 
that similar specific substances antagonistic to the pneumococcus are pro- 
duced in human beings infected with this organism, and the crisis of 
pneumonia is explained by the formation and accumulation of these sub- 
stances in the body. 

Many trials have been made of the curative value of antipneumococcic 



LOBAR PNEUMONIA. 



113 



serum in the treatment of pneumonia, the serum made by Pane having 
been most extensively employed. Thus far it has not been shown that 
this serum influences in any marked degree the course of the disease 
in man. 

Morbid Anatomy. — Since the time of Laennec, pathologists have 
recognized three stages in the inflamed lung — engorgement, red hepatiza- 
tion, and gray hepatization. 

In the stage of engorgement the lung tissue is deep red in color, firmer 
to the touch, and more solid, and on section the surface is bathed with 
blood and serum. It still crepitates, though not so distinctly as healthy 
lung, and excised portions float. The air-cells can be dilated by insuffla- 
tion from the bronchus. Microscopical examination shows the capillary 
vessels to be greatly distended, the alveolar epithelium swollen, and the 
air-cells occupied by a variable number of blood-corpuscles and detached 
alveolar cells. In the stage of red hepatization the lung tissue is solid, firm, 
and airless. If the entire lobe is involved it looks voluminous, and shows 
indentations of the ribs. On section the surface is dry, reddish brown in 
color, and has lost the deeply congested appearance of the first stage. One 
of the most remarkable features is the friability; in striking contrast to 
the healthy lung, which is torn with difficulty, a hepatized organ can be 
readily broken by the finger. Careful inspection shows that the surface 
is distinctly granular, the granulations representing fibrinous plugs filling 
the air-cells. The distinctness of this appearance varies greatly with the 
.size of the alveoli, which are about 0.10 mm. in diameter in the infant, 
0.15 or 0.16 in the adult, and from 0.20 to 0.25 in old age. On scraping 
the surface with a knife a reddish viscid serum is removed, containing small 
granular masses. The smaller bronchi often contain fibrinous plugs. If 
the lung has been removed before the heart, it is not uncommon to find 
solid moulds of clot filling the blood-vessels. Microscopically, the air-cells 
are seen to be occupied by coagulated fibrin in the meshes of which are red 
blood-corpuscles, polynuclear leucocytes, and alveolar epithelium. The 
alveolar walls are infiltrated and leucocytes are seen in the interlobular 
tissues. Cover-glass preparations from the exudate, and thin sections show, 
as a rule, the diplococci already referred to, many of which are contained 
within cells. Staphylococci and streptococci may also be seen in some 
cases. In the stage of gray hepatization the tissue has changed from a 
reddish-brown to a grayish-white color. The surface is moister, the exudate 
obtained on scraping is more turbid, the granules in the acini are less dis- 
tinct, and the lung tissue is still more friable. Histologically, in gray 
hepatization, it is seen that the air-cells are densely filled with leucoevlos, 
the fibrin network and the red blood-corpuscles have disappeared. A more 
advanced condition of gray hepatization is that known as purulent 
infiltration, in which the lung tissue is softer and bathed with a purulent 
fluid. 

The stage of gray hepatization appears to be the first step in the process 
•of resolution. The exudate is softened, the cell elements are disintegrated 
and rendered capable of absorption. When the purulent infiltration of 
the lung tissue reaches the grade sometimes seen post mortem, it is prob- 



114 



SPECIFIC INFECTIOUS DISEASES. 



able that resolution could not take place. Small abscess cavities may arise, 
and by their fusion larger ones. Often in one lung, or even in one lobe, 
the various stages of the process may be seen, and the passage of the en- 
gorgement into red hepatization and of the latter into the gray stage can 
be readily traced. 

The general details of the morbid anatomy of pneumonia may be 
gathered from the following facts, based on 100 autopsies, made by me at 
the General Hospital, Montreal: In 51 cases the right lung was affected; 
in 32, the left; in 17, both organs. In 27 cases the entire lung, with the 
exception, perhaps, of a narrow margin at the apex and anterior border, 
was consolidated. In 34 cases, the lower lobe alone was involved; in 13 
cases, the upper lobe alone. When double, the lower lobes were usually 
affected together, but in three instances the lower lobe of one and the 
upper lobe of the other were attacked. In three cases also, both upper 
lobes were affected. Occasionally the disease involves the greater part of 
both lungs; thus, in one instance the left organ with the exception of the 
anterior border was uniformly hepatized, while the right was in the stage 
of gray hepatization, except a still smaller portion in the corresponding 
region. In a third of the cases, red and gray hepatization existed together. 
In 22 instances there was gray hepatization. As a rule the unaffected por- 
tion of the lung is congested or oedematous. When the greater portion of 
a lobe is attacked, the uninvolved part may be in a state of almost gelati- 
nous oedema. The unaffected lung is usually congested, particularly at 
the posterior part. This, it must be remembered, may be largely due to 
post-mortem subsidence. The uninflamed portions are not always con- 
gested and oedematous. The upper lobe may be dry and bloodless when 
the lower lobe is uniformly consolidated. The average weight of a normal 
lung is about 600 grammes, while that of an inflamed organ may be 1,500, 
2,000, or even 2,500 grammes. 

The bronchi contain, as a rule, at the time of death a frothy serous 
fluid, rarely the tenacious mucus so characteristic of pneumonic sputum. 
The mucous membrane is usually reddened, rarely swollen. In the affected 
areas the smaller bronchi often contain fibrinous plugs, which may extend 
into the larger tubes, forming perfect casts. The bronchial glands are 
swollen and may even be soft and pulpy. The pleural surface of the in- 
flamed lung is invariably involved when the process becomes superficial. 
Commonly, there is only a thin sheeting of exudate, producing slight 
turbidity of the membrane. In only two of the hundred instances the 
pleura was not involved. In some cases the fibrinous exudate may form a 
creamy layer an inch in thickness. A serous exudation of variable amount 
is not uncommon. 

Lesions in other Organs. — The heart is distended with firm, tenacious 
coagula, which can be withdrawn from the vessels as dendritic moulds. 
In no other acute disease do we meet with coagula of such solidity and 
firmness. The distention of the right chambers of the heart is particu- 
larly marked. The left chambers are rarely distended to the same degree. 
The spleen is often enlarged, though in only 35 of the 100 cases was the 
weight above 200 grammes. The kidneys show parenchymatous swelling, 



LOBAR PNEUMONIA. 



115 



turbidity of the cortex, and, in a very considerable proportion of the cases 
— 25 per cent — chronic interstitial changes. 

Pericarditis is not infrequent, and occurs more particularly with pneu- 
monia of the left side and with double pneumonia. In 5 of the 100 autop- 
.sies it was present, and in 4 of them the lappet of lung overlying the peri- 
cardium with its pleura was involved. Endocarditis is more frequent and 
occurred in 16 of the 100 cases. In 5 of these the endocarditis was of the 
simple character; in 11 the lesions were ulcerative. Fatty degeneration 
•of the heart is not common except in protracted cases. 

Meningitis is not infrequently found, and in many cases is associated 
with malignant endocarditis. It was present in 8 of the 100 autopsies. 
•Of 20 cases of meningitis in ulcerative endocarditis 15 occurred in pneu- 
monia. The meningeal inflammation in these cases is usually cortical. 

Croupous or diphtheritic inflammation may occur in other parts. A 
croupous colitis, as pointed out by Bristowe, is not very uncommon. It 
occurred in 5 of my 100 post-mortems. It is usually a thin, flaky exuda- 
tion, most marked on the tops of the folds of the mucous membrane. In 
1 case there was a patch of croupous gastritis, covering an area of 12 by 
•8 cm., situated to the left of the cardiac orifice. 

The liver shows parenchymatous changes and often extreme engorge- 
ment of the hepatic veins. 

Symptoms. — Course of the Disease in Typical Cases. — We know but 
little of the incubation period in lobar pneumonia. It is probably very 
short. There are sometimes slight catarrhal symptoms for a day or two. 
As a rule, the disease sets in abruptly with a severe chill, which lasts from 
fifteen to thirty minutes or longer. In no acute disease is an initial chill 
so constant or so severe. The patient may be taken abruptly in the midst 
•of his work, or may awaken out of a sound sleep in a rigor. The tempera- 
ture taken during the chill shows that the fever has already begun. If 
seen shortly after the onset, the patient has usually features of an acute 
fever, and complains of headache and general pains. Within a few hours 
pain in the side develops, often of an agonizing character; a short, dry, 
painful cough begins, and the respirations are increased in frequency. 
When seen on the second or third day, the picture in typical pneumonia 
is quite pathognomonic; more so, perhaps, than that presented by any 
other acute disease. The patient lies flat in bed, often on the affected 
side; the face is flushed, particularly one or both cheeks; the breathing is 
hurried, accompanied often with a short expiratory grunt; the alae nasi 
dilate with each inspiration; herpes is usually present on the lips or nose; 
the eyes are bright, the expression is anxious, and there is a frequent short 
cough which makes the patient wince and hold his side. The expectora- 
tion is blood-tinged and extremely tenacious. The temperature may bo 
101° or 105°. The pulse is full and bounding and the pulse-respiration 
ratio much disturbed. Examination of the lung shows the physical signs 
of consolidation — blowing breathing and fine rales. After persisting for 
from seven to ten days the crisis occurs, and with a fall in the temperature 
the patient passes from the condition of extreme distress and anxiety to one 
•of comparative comfort. 



110 



SPECIFIC INFECTIOUS DISEASES. 



Special Features. — The fever rises rapidly, and the height may be 
104° or 105° within twelve hours. Having reached the fastigium, it is 



12 13 U 15 16 17 IS 10 



Re&p. 



Temp 
109 



96 
Temp 



Resp 
Stools 



)ay of 

] Msease 




BLACK, TEMPERATURE 



RED, pulse; BLUE, RESPIRATION. 

Chart IX. — Fever, pulse, and respirations in lobar pneumonia. 



remarkably constant. Often the two-hour temperature chart will not show 
for two days more than a degree of variation. In children and in cases 



LOBAR PNEUMONIA. 



117 



without chill the rise is more gradual. In old persons and in drunkards 
the temperature range is lower than in children and in healthy individuals; 
indeed, one occasionally meets with an afebrile pneumonia. 

The Crisis. — After the fever has persisted for from five to nine or ten 
days there is an abrupt drop, known as the crisis, which is perhaps the 
most characteristic feature of lobar pneumonia. The day of the crisis is 
variable. It is very uncommon before the third day, and rare after the 
twelfth. I have twice seen it as early as the third day. From the time of 
Hippocrates it has been thought to be more frequent on the uneven days, 
particularly the fifth and seventh. A precrilical rise of a degree or two 
may occur. In one case the temperature rose from 105° to nearly 107°, and 
then in a few hours fell to normal. Not even after the chill in malarial 
fever do we see such a prompt and rapid drop in the temperature. The 
usual time is from five to twelve hours, but often in an hour there may 
occur a fall of six or eight degrees (S. West). The temperature may be 
subnormal after the crisis, as low as 96° or 97°. Usually with the crisis 
there is an abundant sweat, and the patient sinks into a comfortable 
sleep. The day after the crisis there may be a slight post-critical rise. 
A pseudo-crisis is not very uncommon, in which on the fifth or sixth day 
the temperature drops from 104° or 105° to 102°, and then rises again. 
When the fall takes place gradually within twenty-four hours it is called 
a protracted crisis. If the fever persists beyond the twelfth day, the fall 
is likely to be by lysis. In children this mode of termination is common, 
and occurred in one third of a series of 183 cases reported by Morrill. 
Occasionally in debilitated individuals the temperature drops rapidly just 
before death; more frequently there is an ante-mortem elevation. In cases 
of delayed resolution the fever may persist for weeks. The crisis is the 
most remarkable single phenomenon of pneumonia. With the fall in the 
fever the respirations become reduced almost to normal, the pulse slows, and 
the patient passes from perhaps a state of extreme hazard and distress to one 
of safety and comfort, and yet, so far as the physical examination indicates, 
there is with the crisis no special change in the local condition in the lung. 

Pain. — There is early a sharp, agonizing pain, generally referred to the 
region of the nipple or lower axilla of the affected side, and much aggra- 
vated on deep inspiration and on coughing. It is associated, as Aretasus 
remarks, with involvement of the pleura. It is absent in central pneu- 
monia, and much less frequent in apex pneumonia. In exceptionaf cases 
the pain is in the abdomen, and I have twice known the suspicion of 
appendicitis raised by the sudden acute onset of the pain, once in the 
region of the navel and once low on the right side. The pain may be 
severe enough to require a hypodermic injection of morphia. 

Dyspnoea is an almost constant feature. Even early in the disease the 
respirations may be 30 in the minute, and on the second or third day be- 
tween 40 and 50. The movements are shallow, evidently restrained, and 
if the patient is asked to draw a deep breath he cries out with the pain. 
Expiration is frequently interrupted by an audible grunt. At first with the 
increased respiration there may be no sensation of distress. Latin- this 
may be present in a marked degree. In children the respirations may bo 



118 



SPECIFIC INFECTIOUS DISEASES. 



80 or even 100. Many factors combine to produce the shortness of breath— 
the pain in the side, the toxaemia, the fever, and the loss of function in a 
considerable area of the lung tissue. Sometimes there appear to be nerv- 
ous factors at work. That it does not depend upon the consolidation is 
shown by the fact that after the crisis, without any change in the local 
condition of the lung, the number of respirations may drop to normal. 
The ratio between the respirations and the pulse may be 1 to 2 or even 1 to 
1.5, a disturbance rarely so marked in any other disease. 

Cough. — This usually comes on with the pain in the side, and at first is 
dry, hard, and without any expectoration. Later it becomes very charac- 
teristic — frequent, short, restrained, and associated with great pain in the 
side. In old persons, in drunkards, in the terminal pneumonias, and some- 
times in young children there may be no cough. After the crisis the cough 
usually becomes much easier and the expectoration more easily expelled. 
The cough is sometimes persistent, continuous, and by far the most aggra- 
vated and distressing symptom of the disease. Paroxysms of coughing of 
great intensify after the crisis suggest a pleural exudate. 

Sputum. — A brisk haemoptysis may be the initial symptom. At first 
the sputum may be mucoid, but usually after twenty-four hours it becomes 
blood-tinged, viscid, and very tenacious. At first quite red from the un- 
changed blood, it gradually becomes rusty or of an orange yellow. The 
tenacious viscidity of the sputum is remarkable; it often has to be wiped 
from the lips of the patient. When jaundice is present it may be green or 
yellow. In low types of the disease the sputum may be fluid and of a 
dark brown color, resembling prune juice. The amount is very variable. 
In children and in old people there may be none, and even in adults cases 
are not very uncommon in which from beginning to close there is no ex- 
pectoration. A common amount is from 150 to 300 ce. daily. After the 
crisis the quantity is variable, abundant in some cases, absent in others. 

Microscopically, the sputum consists of leucocytes, mucus corpuscles, 
red blood-corpuscles in all stages of degeneration, and bronchial and alve- 
olar epithelium. Haematoidin crystals are occasionally met with. Of micro- 
organisms the pneumococcus is usually present, and sometimes Friedlander's 
bacillus. Very interesting constituents are small cell moulds of the alveoli 
and the fibrinous casts of the bronchioles; the latter may be very plainly 
visible to the naked eye, and sometimes may form good-sized dendritic casts. 
Chemically, the expectoration is particularly rich in calcium chloride. 

Physical Signs. — Inspection. — The position of the patient is not 
constant. He usually rests more comfortably on the affected side, or he 
is propped up with the spine curved toward it. Orthopnoea is not nearly 
so frequent as in heart-disease. 

In a small lesion no differences may be noted between the sides; as 
a rule, movement is much less on the affected side, which may look 
larger. With involvement of a lower lobe, the apex on the same side may 
show greater movement. The compensatory increased movement on the 
sound side is sometimes very noticeable even before the patient's chest 
is bared. The intercostal spaces are not usually obliterated. When the 
cardiac lappet of the left upper lobe is involved there may be a marked 



LOBAR PNEUMONIA. 



119 



increase in the area of visible cardiac pulsation. Pulsation of the affected 
lung may cause a marked movement of the chest wall (Graves). Other 
points to be noticed in the inspection are the frequency of the respiration, 
the action of the accessory muscles, such as the sterno-cleido-mastoids and 
scaleni, and the dilatation of the nostrils with each inspiration. 

Mensuration may show a definite increase in the volume of the side 
affected, rarely more, however, than 1 or \\ cm. 

Palpation. — The lack of expansion on the affected side is sometimes 
more readily perceived by touch than by sight. The pleural friction may 
be felt. On asking the patient to count, the voice fremitus is greatly in- 
creased in comparison with the corresponding point on the healthy side. 
It is to be remembered that if the bronchi are filled with thick secretion, 
or if, in what is known as massive pneumonia, they are filled with fibrinous 
exudate, the tactile fremitus may be diminished. It is always well to ask 
the patient to cough before testing the fremitus. 

Percussion. — In the stage of engorgement the note is higher pitched 
and may have a somewhat tympanitic quality, the so-called Skoda's reso- 
nance. This can often be obtained over the lung tissue just above a con- 
solidated area. When the lung is hepatized, the percussion note is dull, 
the quality varying a good deal from a note which has in it a certain tym- 
panitic quality to one of absolute flatness. There is not the wooden flat- 
ness of effusion and the sense of resistance is not so great. During resolu- 
tion the tympanitic quality of the percussion note usually returns. For 
weeks or months after convalescence there may be a higher-pitched note 
on the affected side. Among variations to be noticed are that Wintricb/s 
change in the percussion note when the mouth is open may be very well 
marked in pneumonia of the upper lobe. Occasionally there is an almost 
metallic quality over the consolidated area, and when this exists with a 
very pronounced amphoric quality in the breathing the presence of a cavity 
may be suggested. In deep-seated pneumonias there may be for several 
days no change in the percussion note, and in a few rare cases percussion 
shows no change throughout the disease. 

Auscultation. — Quiet, suppressed breathing in the affected part is often 
a marked feature in the early stage, and is always suggestive. Very early 
there is heard at the end of inspiration the fine crepitant rale, a series of 
minute cracklings heard close to the ear, and perhaps not audible until a. 
full breath is drawn. This is probably a fine pleural crepitus, as J. B. 
Learning maintained; it is usually believed to be produced in the air-cells 
and finer bronchi by the separation of the sticky exudate. At this stage, 
before consolidation has occurred, the breath-sounds may be, as before men- 
tioned, much feebler than in health, but on drawing a long breath they 
may have a harsh quality, to which the term broncho-vesicular has been 
applied. In the stage of red hepatization and when dulness is well de- 
fined, the respiration is tubular, similar to that heard in health over the 
larger bronchi. With this blowing breathing there may be no rales, and 
it may^ present an intensity unknown in any other pulmonary all'eetion. 
It is simply the propagation of the laryngeal and tracheal sounds through 
the bronchi and the consolidated lung tissue. The permeability of the 



120 



SPECIFIC INFECTIOUS DISEASES. 



bronchi is essential to its production. Tubular breathing is absent in cer- 
tain cases of massive pneumonia in which the larger bronchi are completely 
filled with exudation. When resolution begins mucous rales of all sizes can 
be heard. At first they are small and have been called the redux-crepitus. 
The voice-sounds are transmitted through the consolidated lung with great 
intensity. This bronchophony may have a curious nasal quality to which 
the term segophony has been given. There are cases in which the consoli- 
dation is deeply seated — so-called central pneumonia, in which the phys- 
ical signs are slight or even absent, yet the cough, the rusty expectoration, 
and general features make the diagnosis certain. 

Circulatory Symptoms. — During the chill the pulse is small, but in 
the succeeding fever it becomes full and bounding. In cases of moderate 
severity it ranges from 100 to 116. It is not often dicrotic. In strong, 
healthy individuals and in children there may be no sign of failing pulse 
throughout the attack. With extensive consolidation the left ventricle 
may receive a very much diminished amount of blood and the pulse in 
consequence may be small. In the old and feeble it may be small and 
rapid from the outset. The pulse may be full, soft, very deceptive, and of 
no value whatever in prognosis. The heart-sounds are usually loud and 
clear. During the intensity of the fever, particularly in children, bruits 
are not uncommon both in the mitral and in the pulmonic areas. The 
second sound over the pulmonary artery is accentuated. Attention to this 
sign gives a valuable indication as to the condition of the lesser circula- 
tion. With distention of the right chambers and failure of the right ven- 
tricle to empty itself completely the pulmonary second sound becomes much 
less distinct. When the right heart is engorged there may be an increase 
in the dulness to the right of the sternum. With gradual heart weakness 
and signs of dilatation the long pause is greatly shortened, the sounds 
approach each other in tone and have a fcetal character (embryocardia). 

There may be a sudden early collapse of the heart with very feeble, 
rapid pulse and increasing cyanosis. I have known this to occur on the 
third day. Even when these symptoms are very serious recovery may take 
place. In other instances without any special warning death may occur 
even in robust, previously healthy men.* The heart weakness may be due 
to paralysis of the vaso-motor centre and consequent lowering of the gen- 
eral arterial pressure. The soft, easily compressed pulse, with the gray, 
ashy facies, cold hands and feet, the clammy perspiration, and the pro- 
gressive prostration tell of a toxic action in the vaso-motor centres. This 
is a feature of the toxaemia to which Romberg and Passler have called atten- 
tion. Endocarditis and pericarditis will be considered under complications. 

Blood. — Anaemia is rarely seen. Bollinger has called attention to an 
oligsemia due to the large amount of exudate. A decrease in the red cells 
may occur at the time of the crisis. There is in most cases a leucocytosis, 
which appears early, persists, and disappears with the crisis. The leuco- 
cytes may number from 12,000 to 40,000 or even 100,000 per cubic milli- 
metre. The fall in the leucocytes is often slower than the drop in the fever, 



* For illustrative cases see Prognosis in Pneumonia, Am. Jr. Med. Sci., Jan., 1897. 



LOBAR PNEUMONIA. 



121 



particularly when resolution is delayed. The annexed chart from J. S. 
Billings' paper (J. H. H. Bulletin, No. 43) shows well the coincident drop in 
the fever and in the number of the leucocytes. The leucocytosis bears rela- 
tion to the extent of the exudate. In malignant pneumonia the leucocytosis 
may be absent, and in any case the continuous absence may be regarded as 
an unfavorable sign. Of 64 cases studied in my clinic during the session 



106 
105 c 

o 

104 

103° 
102° 
101° 

100° 
99° 
98° 



20,000 
18,000 
16,000 
14,000 
12,000 
10,000 
8,000 
6,000 



i,000 
2,000 



16 17 13 19 20 21 22 


6 in 6 12 6 in 6 12 6 m 6 12 6 m 6 12 6 m 6 12 6 m 6 12 6 m 6 


































































































































































































































































































N 


























































A 






















































\ 
































































































































































































































































































































































A 






A 






















































/ 




V 



















































V 










_ 














.__ 





. 








































































































































































































































— 












































































































| 






















































1 




































































































































































































































































































- 




— 


























































- 










































































































































































- 


















































































































































































































































































































































































































— 







































































































































Chart X. 



of 1900-1901, the highest leucocytosis was 64,000, the lowest 1,400. A 
striking feature in the blood-slide is the richness and density of the fibrin 
network. This corresponds to the great increase in the fibrin eli'inents. 



122 



SPECIFIC INFECTIOUS DISEASES. 



which has long been known to occur in pneumonia, the proportion rising- 
from 1 to 10 parts per thousand. Hayem describes the blood-plates as 
greatly increased. As stated, the micrococci can frequently be cultivated 
from the blood. 

Digestive Organs. — The tongue is white and furred, and in severe- 
toxic cases rapidly becomes dry. Vomiting is not uncommon at the onset 
in children. The appetite is lost. Constipation is more common than 
diarrhoea, A distressing and sometimes dangerous symptom is meteorism. 
Fibrinous, pneumococcic exudates may occur in the conjunctiva?, nose > 
mouth, prepuce, and anus (Gary). The liver may be depressed by the large 
right lung, or enlarged from the engorged right heart, or as a result of 
the infection. The spleen is usually enlarged, and the edge can be felt 
during a deep inspiration. 

Skin. — Among cutaneous symptoms one of the most interesting is the 
association of herpes with pneumonia. Not excepting malaria, we see 
labial herpes more frequently in this than in any other disease, occurring, 
as it does, in from 12 to 40 per cent of the cases. It is supposed to be of 
favorable prognosis, and figures have been quoted in proof of this asser- 
tion. It may also occur on the nose, genitals, and anus. Its significance 
and relation to the disease are unknown. It is scarcely necessary to men- 
tion the theory which has been advanced, that it is an external expression 
of a neuritis which involves the pneumogastric and induces the pneumo- 
nia. At the height of the disease sweats are not common, but at the crisis 
they may be profuse. Eedness of one cheek is a phenomenon long recog- 
nized in connection with pneumonia, and is usually on the same side as 
the disease. Jaundice is referred to among the complications. 

Urine. — Early in the disease it presents the usual febrile characters 
of high color, high specific gravity, and increased acidity. A trace of albu- 
min is very common. There may be tube-casts and in a few instances the 
existence of albumin, tube-casts, and blood indicate the presence of an 
acute nephritis. The urea and uric acid are usually increased at first, but 
may be much diminished before the crisis, to increase greatly with its onset. 
Eobert Hutchison's recent researches show that a true retention of chlo- 
rides within the body takes place, the average amount being about 2 grams 
daily. It is a more constant feature of pneumonia than of any other 
febrile disease, and this being the case, a diminution of the chlorides in the 
urine may be of value in the diagnosis from pleurisy with effusion or em- 
pyema. It is to be remembered that in dilatation of the stomach chlorides 
may be absent. Hematuria is a rare complication. 

Cerebral Symptoms. — Headache is common. Convulsions occur 
frequently at the outset in children. Apart from meningitis, which will 
be considered separately, one may group the cases with marked cerebral 
features into — 

First, the so-called cerebral pneumonias of children, in which the dis- 
ease sets in with a convulsion and there are high fever, headache, delirium, 
great irritability, muscular tremor, and perhaps retraction of the head 
and neck. The diagnosis of meningitis is usually made, and the local 
affection may be overlooked. 



LOBAR PNEUMONIA. 



123 



Secondly, the cases with maniacal symptoms. These may occur at the 
very outset, and I once performed an autopsy on a case in which there was 
no suspicion whatever that the disease was other than acute mania. The 
house physician should give instructions to the nurses to watch such cases 
very carefully. On March 22, 1894, a patient who had been doing very 
well, with the exception of slight delirium, while the orderly was out of the 
room for a few moments, got up, raised the window, and jumped out, sus- 
taining a fracture of the leg and of the upper lumbar vertebrae, of which 
he died. 

Thirdly, alcoholic cases with the features of delirium tremens. It 
should be an invariable rule, even if fever be not present, to examine the 
lungs in a case of mania a potu. 

Fourthly, cases with toxic features, resembling rather those of uraemia. 
Without a chill and without cough or pain in the side, a patient may de- 
velop fever, a little shortness of breath, and then gradually grow dull men- 
tally, and within three days be in a condition of profound toxaemia with 
low, muttering delirium. 

It is stated that apex pneumonia is more often accompanied with severe 
delirium. Occasionally the cerebral symptoms develop immediately after 
the crisis. Mental disturbance may persist during and after convalescence, 
and in a few instances delusional insanity follows, the outlook in which is 
favorable. 

Complications. — Compared with typhoid fever, pneumonia has but 
few complications and still fewer sequelae. The most important are the 
following: 

Pleurisy is an inevitable event when the inflammation reaches the sur- 
face of the lung, and thus can scarcely be termed a complication. But there 
are cases in which the pleuritic features take the first place — cases to which 
the term pleuro-pneumonia is applicable. The exudation may be sero- 
fibrinous with copious effusion, differing from that of an ordinary acute 
pleurisy in the greater richness of the fibrin, which may form thick, 
tenacious, curdy layers. Pneumonia on one side with extensive pleurisy 
on the other is sometimes a puzzling complication to diagnose and an 
aspirator needle may be required to settle the question. Empyema is one 
of the most common complications, and has of late increased in frequency. 
During the eight years, 1891-98, there were at Guy's Hospital 7 cases of 
empyema among 445 cases of pneumonia, while in the eight years, 1891-'98, 
there were 38 cases among 896 cases of pneumonia (Hale While). Influenza 
may be responsible for the increase. The pneumococcus is usually present; 
in a few the streptococcus, in which case the prognosis is not so good. 
Recurrence of the fever after the crisis or persistence of it after the tenth 
day with sweats, leucocytosis, and perhaps an aggravation of the cough, 
are suspicious symptoms. Dulness continues at the base, or may have 
extended. The breathing is feeble and there are no rales. Such a condition 
may be closely simulated, of course, by the thickened pleura. Exploratory 
aspiration may settle the question at once. There are obscure cases in 
which the pus has been found only after operation, as the collection may 
be very small. 
8 



124 



SPECIFIC INFECTIOUS DISEASES. 



Pericarditis is more common in the pneumonia of children, particu- 
larly when double, and it is said with the pneumonia of the left side. It 
is particularly apt to follow or to be associated with acute rheumatism. It 
was present, as I stated, in 5 of my 100 autopsies. Though usually plastic, 
there may be much serous effusion. There is rarely any difficulty in the 
diagnosis, but when the pneumonia involves the portion of lung covering 
the pericardium, there may be difficulty in determining, by physical signs, 
the existence of fluid. The increase in the dyspnoea, the greater feebleness 
of the pulse, and the gradual suppression of the heart-sounds will give the 
most valuable indications. In some instances the fluid is purulent. Though 
a very serious event, it is surprising how often recovery takes place even 
in the most desperate cases of pneumonia complicated with pericarditis, 
a point to which I have heard Murchison refer. 

Endocarditis is still more frequent, and in my 100 autopsies was pres- 
ent in 16. I called attention in the Gulstonian lectures for 1885 to the 
great frequency of this complication. Of 209 cases of malignant endo- 
carditis collected from the literature, 54 occurred in this disease. Sub- 
sequent observations have fully confirmed this statement. Kanthack found 
an antecedent pneumonia in 14.2 per cent of all instances of infective endo- 
carditis. It is much more common in the left heart than in the right. 
It is particularly liable to attack persons with old valvular disease. The 
pneumococcus has been found in the vegetations. There may be no symp- 
toms indicative of this complication even in very severe cases. It may, 
however, be suspected in cases (1) in which the fever is protracted and 
irregular; (2) when signs of septic mischief arise, such as chills and sweats; 
(3) when embolic phenomena appear. The frequent complication of 
meningitis with the endocarditis of pneumonia, which has already been 
mentioned, gives prominence to the cerebral symptoms in these cases. The 
physical signs may be very deceptive. There are instances in which no 
cardiac murmurs have been heard. In others the occurrence under ob- 
servation of a loud, rough murmur, particularly if diastolic, is extremely 
suggestive. 

Myocarditis is rare. 

Ante-mortem heart-clots are excessively rare. In protracted cases 
thrombi occasionally form in the veins, usually the femoral or internal 
saphenous. Welch (Allbutt's System) has collected 23 cases, occurring 
usually during convalescence. Phlegmasia alba dolens sometimes follows. 
The condition is rarely serious. A rare complication is embolism of one 
of the larger arteries. I saw in Montreal an instance of embolism of the 
femoral artery at the height of pneumonia, which necessitated amputation 
at the thigh. The patient recovered. Aphasia has been met with in a few 
instances, setting in abruptly with or without hemiplegia. 

Meningitis is perhaps the most serious complication of pneumonia. It 
varies very much at different times and in different regions. My Montreal 
experience is rather exceptional, as 8 per cent of the fatal cases had this 
complication. It usually comes on at the height of the fever, and in the 
majority of the cases is not recognized unless, as before mentioned, the 
base is involved, which is not common. Meningitis may occur later in 



LOBAR PNEUMONIA. 



125 



the disease, and is then more easily diagnosed. In some cases it is associ- 
ated with infective endocarditis. The pneumococcns has been found in 
the exudate. 

Peripheral neuritis is a rare complication, of which several cases have 
been described. I saw one well-marked instance following pneumonia and 
influenza in the spring of 1890. There was neuritis of the left arm with 
considerable wasting. 

Gastric complications are rare. A croupous gastritis has already been 
mentioned. The croupous colitis may induce severe diarrhoea. Jaundice 
is one of the most interesting complications of pneumonia and occurs with 
curious irregularity in different outbreaks of the disease. It sets in early, 
is rarely very intense, and has not the characters of obstructive jaundice. 
There are cases in which it assumes a very serious form. The mode of pro- 
duction is not well ascertained. It does not appear to bear any definite 
relation to the degree of hepatic engorgement and it is not always due 
to catarrh of the ducts. Possibly it may be, in great part, hematogenous. 

Parotitis occasionally occurs, commonly in association with endocar- 
ditis. In children middle-ear disease is not an infrequent complication. 

Bright' s disease does not often follow pneumonia. Peritonitis is ex- 
ceedingly rare. 

The relations of rheumatism and pneumonia are very interesting. The 
arthritis may precede the onset, and the pneumonia, possibly with endo- 
carditis and pleurisy, may occur as a complication of the rheumatism. In 
other instances at the height of an ordinary pneumonia one or two joints 
may become red and sore. On the other hand, after the crisis has occurred 
pains and swelling may come on in the joints. 

Relapse. — There are cases in which from the ninth to the eleventh 
day the fever subsides, and after the temperature has been normal for a 
day or two a rise occurs and fever may persist for another ten days or even 
two weeks. Though this might be termed a relapse, it is more correct to 
regard it as an instance of an anomalous course of delayed resolution. 
Wagner, who has studied the subject carefully, says that in his large ex- 
perience of 1,100 cases he met with only 3 doubtful cases. When it does 
occur, the attack is usually abortive and mild. In the case of Z. R. (Medical 
No. 4223), with pneumonia of the right lower lobe, crisis occurred on 
the seventh day, and after a normal temperature for thirteen days he was 
discharged. That night he had a shaking chill, followed by fever, and he 
had recurring chills with reappearance of the pneumonia. In a second 
case (Medical No. 4538) crisis occurred on the third day, and there was 
recurrence of pneumonia on the thirteenth day. 

Recurrence is more common in pneumonia than in any other acute 
disease. Rush gives an instance in which there were 28 attacks. Other 
authorities narrate cases of 8, 10, and even more attacks. 

Convalescence in pneumonia is usually rapid, and sequelae arc rare. 
After the crisis, sudden death has occurred when the patient has got up toe 
soon. Lusk, of Weymouth, writes of such a case. With the onset of fever 
and persistence of the leucocytes the affected side should he very carefully 
examined for pleurisy. With a persistence of the dulness the physical 



126 



SPECIFIC INFECTIOUS DISEASES. 



signs may be obscure, but the use of a small exploratory needle will help 
to clear the diagnosis. 

Clinical Varieties. — 1. Local variation are responsible for some of 
the most marked deviations from the usual type. 

Apex pneumonia is said to be more often associated with adynamic 
features and with marked cerebral symptoms. The expectoration and 
cough may be slight. I can not say that in my experience the cerebral 
symptoms in adults have been more marked in this form, nor do I think 
it necessarily graver than if situated at the base. 

Migratory or creeping pneumonia, a form which successively involves 
one lobe after the other. 

Double pneumonia has no peculiarities other than the greater danger 
connected with it. 

Massive pneumonia is a rare form, in which not alone the air-cells but 
the bronchi of an entire lobe or even of a lung are filled with the fibrinous 
exudate. The auscultatory signs are absent; there is neither fremitus nor 
tubular breathing, and on percussion the lung is absolutely flat. It closely 
resembles pleurisy with effusion. The moulds of the bronchi may be ex- 
pectorated in violent fits of coughing. 

Central Pneumonia. — The inflammation may be deep-seated at the 
root of the lung or centrally placed in a lobe, and for several days the diag- 
nosis may be in doubt. It may not be until the third or fourth day that a 
pleural friction is detected, or that dulness or blowing breathing and rales 
are recognized. I saw in 1898 with Dr. Henry Adler and Dr. Chew an 
instance in which at the end of the fourth day in a young, thin-chested 
girl all the usual symptoms of pneumonia were present without any phys- 
ical signs other than a few clicking rales at the left apex behind. The thin- 
ness of the patient greatly facilitated the examination. The general fea- 
tures of pneumonia continued, and the crisis occurred on the seventh day. 

2. Pneumonia in Infants. — It is sometimes seen in the newborn. In 
infants it very often sets in with a convulsion. The summit of the lung 
seems more frequently involved than in adults, and the cerebral symptoms 
are more marked. The torpor and coma, particularly if they follow con- 
vulsions, and the preliminary stage of excitement, may lead to the diag- 
nosis of meningitis. Pneumonic sputum is rarely seen in children. 

3. Pneumonia in the Aged. — The disease may be latent and set in with- 
out a chill; the cough and expectoration are slight, the physical signs ill- 
defined and changeable, and the constitutional symptoms out of all pro- 
portion to the extent of the local lesion. 

4. Pneumonia in Alcoholic Subjects. — The onset is insidious, the symp- 
toms masked, the fever slight, and the clinical picture usually that of 
delirium tremens. The thermometer alone may indicate the presence of 
an acute disease. Often the local condition is overlooked, as the patient 
makes no complaint of pain, and there may be very little shortness of 
breath, no cough, and no sputum. 

5. Terminal Pneumonia. — The wards and the post-mortem room show 
a very striking contrast in their pneumonia statistics, owing to the occur- 
rence of what may be called terminal pneumonia. During the winter 



LOBAR PNEUMONIA. 



127 



months patients with chronic pulmonary tuberculosis, arterio-sclerosis, 
heart disease, Bright's disease, and diabetes are not infrequently carried 
off by a pneumonia which may give few or no signs of its presence. There 
may be a slight elevation of temperature, with increase in the respirations, 
but the patient is near the end and perhaps not in a condition in which 
a thorough physical examination can be made. The autopsy may show 
pneumonia of the greater part of one lower lobe or of the apex, which had 
entirely escaped notice. In diabetic patients the disease often runs a rapid 
and severe course, and may end in abscess or gangrene. 

Some of the most remarkable variations in the clinical course of pneu- 
monia depend probably upon the severity, possibly upon the nature of the 
infective agent. Further investigation may enable us to say how far the 
associated organisms, so often present, may be responsible for the differ- 
ences in the clinical course. 

6. Secondary Pneumonias. — These are met with chiefly in the specific 
fevers, particularly diphtheria, typhoid fever, typhus, influenza, and the 
plague. Anatomically, they rarely present the typical form of red or gray 
hepatization. The surface is smoother, not so dry, and it is often a pseudo- 
lobar condition, a consolidation caused by closely set areas of lobular in- 
volvement. Histologically, they are characterized in many instances by a 
more cellular, less fibrinous exudate, which may also infiltrate the alveolar 
walls. Bacteriologically, a large number of different organisms have been 
found, the specific microbe of the primary disease, usually in association 
with the streptococcus pyogenes or the staphylococcus; in some instances 
the colon bacillus has been present. Finkler has attempted to separate a 
special form, which he calls the acute cellular pneumonia, to which most of 
these secondary types conform and which have the histological characters 
already referred to (Die Acuten Lungenentzundungen, 1891). 

The symptoms of the secondary pneumonias often lack the striking 
definiteness of the primary croupous pneumonia. The pulmonary features 
may be latent or masked altogether. There may be no cough and only a 
slight increase in the number of respirations. The lower lobe of one lung 
is most commonly involved, and the physical signs are obscure and rarely 
amount to more than impaired resonance, feeble breathing, and a few 
crackling rales. In some instances when the consolidation is extensive the 
breathing is distinctly tubular. 

7. Epidemic pneumonia has already been referred to. It is, as a rule, 
more fatal, and often displays minor complications which differ in differ- 
ent outbreaks. In some the cerebral manifestations are very marked; in 
others, the cardiac; in others, again, the gastro-intestinal. 

8. Larval Pneumonia. — Mild, abortive types are seen, particularly in 
institutions when pneumonia is prevailing extensively. A patient may 
have the initial symptoms of the disease, a slight chill, moderate fever, 
a few indefinite local signs, and herpes. The whole process may only lasl 
for two or three days; some authors recognize even a one-day pneumonia. 

9. Asthenic, Toxic, or Typhoid Pneumonia. — The fcoxaemic features 
dominate the scene throughout. The local lesions may be slighi in exten 
and the subjective phenomena of the disease absent. The nervous symp- 



128 



SPECIFIC INFECTIOUS DISEASES. 



toms usually predominate. There are delirium, prostration, and early 
weakness. Very frequently there is jaundice. Gastro-intestinal symptoms 
may be present, particularly diarrhoea and meteorism. In such a case, seen 
about the end of the first week, it may be difficult to say whether the con- 
dition is one of asthenic pneumonia or one of typhoid fever which has set 
in with early localization in the lung. Here the Widal reaction would be 
an important aid. In these cases there is really a pneumococcus septi- 
caemia, and the organisms may sometimes be isolated from the blood. 
Possibly, too, there is a mixed infection, and the streptococcus pyogenes 
may be in large part responsible for the toxic features of the disease. 

10. Association of Pneumonia with other Diseases. — (a) With Malaria. 
— A malarial pneumonia is described by many observers and thought to be 
particularly prevalent in some parts of this country. One hears of it, in- 
deed, even where true malaria is rarely seen. With our large experience in 
malaria, amounting now to nearly 2,000 cases, and a considerable number 
of pneumonia patients every year, we have only had a few cases in which 
the latter disease has set in during malarial fever, or vice versa. In 
either case the malaria yields promptly to the action of quinine. So far as 
the Southern States are concerned, the question of a special form was 
thrashed out years ago in a discussion between Manson and W. T. Howard, 
and was decided in the negative. A form of pneumonia directly dependent 
upon the malarial parasite is unknown. We have not been able to recog- 
nize here a pneumonia which is influenced in any way by the malarial 
poison. Such a case as the following we see occasionally: A patient was 
admitted, March 16, 1891, with tertian malarial fever. The lungs were 
clear. A pneumonia began thirty-six hours after admission. Quinine was 
given that evening, and the malarial organisms rapidly disappeared from 
the blood. There was successive involvement of the right lower, the middle, 
and the left lower lobe. The temperature fell by crisis on the 24th, and 
there were no features in the disease whatever suggestive of malaria. In 
other instances we have found a chill in the course of an ordinary pneu- 
monia to be associated with a malarial infection, and quinine has rapidly 
and promptly caused the disappearance of the parasites from the blood. 

(b) Pneumonia and Acute Rheumatism. — We have already spoken under 
complications of this association, which is more frequently seen in children. 

(c) Pneumonia and Tuberculosis. — Many subjects of chronic pulmonary 
tuberculosis die of an acute croupous pneumonia. A point to be specially 
borne in mind is the fact that acute tuberculous pneumonia may set in 
with all the features and physical signs of fibrinous pneumonia (see page 
290). 

For the consideration of the association of pneumonia with typhoid 
fever and influenza, the reader is referred to the sections on those diseases. 

11. Post-operation Pneumonia. — Before the days of anaesthesia, lobar 
pneumonia was a well-recognized cause of death after surgical injuries and 
operations. Norman Cheevers, in an early number of the Guy's Hospital 
Eeports, calls attention to it as one of the most frequent causes of death 
after surgical procedures, and Erichsen states that of 41 deaths after sur- 
gical injuries 23 cases exhibited signs of pneumonia. The lobular form 



LOBAR PNEUMONIA. 



129 



is the most frequent. I have already referred to the contusion-pneumonia 
described by Litten. 

12. Ether Pneumonia. — The question of a direct relation between ether 
narcosis and pneumonia has been much discussed of late years, having 
been raised by Mr. Lucas, of Guy's Hospital. The statistics are by no 
means unanimous. Prescott, of Boston, in 40,000 cases found only 3 of 
acute lobar pneumonia. The London anaesthetists, particularly Hewitt 
and Silk, seem also to have had a fortunate experience, Silk having found 
among 5,000 cases 13 of pneumonia; 8 of these were tongue or jaw cases. 
The German experience is very different. Yon Beck states that, owing to 
the injurious after-effects upon the respiratory tract, the use of ether has 
been largely restricted in Czerny's clinic. Gurlt reports 52,177 cases, with 
30 cases of pneumonia and 15 deaths. Of 15 cases of pneumonia following 
anaesthesia on the surgical side of the Johns Hopkins Hospital, 12 were 
broncho-pneumonias; there were 7 deaths and 8 recoveries; 79 per cent of 
the cases followed abdominal section or hernia operations. Czerny sug- 
gests that the relation of these ether pneumonias to abdominal operations 
is associated with the pain on coughing, which leads to an accumulation 
of secretion, and through this to retention or aspiration pneumonia. 
Among the various views brought forward to account for it are the rapid 
evaporation of the ether, causing chilling of the pulmonary tissues, chill- 
ing of the patient at the time of operation, infection from the inhaler, and 
direct action of the ether. 

The probability is that the prolonged etherization lowers the vitality 
of the tissues of the finer bronchi and permits the pathogenic organisms 
(which are almost always present) to do their work. The pneumonia is 
more frequently lobular than lobar. Neuwerck, and subsequently Whitney, 
have suggested thorough disinfection of the mouth and throat before 
operation. 

13. Delayed Resolution in Pneumonia. — The lung is restored to its nor- 
mal state partly by the expectoration of the exudate, partly by its liquefac- 
tion and absorption. There are cases in which resolution takes place rapidly 
without any increase in (or, indeed, without any) expectoration; on the 
other hand, during resolution it is not uncommon to find in the sputa the 
little plugs of fibrin and leucocytes which have been loosened from the 
air-cells and expelled by coughing. In a majority of cases both processes 
are probably at work. A variable time is taken in the restoration of the 
lung. Sometimes within a week or ten days the dulness is greatly dimin- 
ished, the breath-sounds become clear, and, so far as physical signs are 
any guide, the lung seems perfectly restored. It is to be remembered that 
in any case of pneumonia with extensive pleurisy a certain amount of 
dulness will persist for months, owing to thickening of the pleura. 

Delayed resolution is a condition which causes much anxiety to the 
physician. While it is perhaps more frequent in debilitated person*, wt 
it is met with in robust, previously healthy individuals, and in cases which 
have had a very typical onset and course. The condition is stated io be 
most frequent in apex pneumonia. Venesection has been assigned as a 



130 



SPECIFIC INFECTIOUS DISEASES. 



cause. There is no question that the solid exudate can persist for creeks 
and yet the integrity of the lung may ultimately be restored. Grissole de- 
scribes the lung from a patient who died on the sixtieth da}', in which the 
affected part showed a condition not unlike that of the acute stage. 

Clinically, there are several groups of cases: First, those in which the 
crisis occurs naturally, the temperature falls and remains normal, but the 
local features persist — well-marked flatness with tubular breathing and 
rales. Eesolution may occur very slowly and gradually, taking from two 
to three weeks. In a second group of cases the temperature falls by lysis, 
and with the persistence of the local signs there is slight fever, sometimes 
sweats and rapid pulse. The condition may persist for three or four weeks, 
or, as in one of my cases, for eleven weeks, and ultimately perfect resolution 
occur. During all this time there may be little or no sputum. The prac- 
titioner is naturally much exercised, and he dreads lest tuberculosis should 
supervene. In a third group the crisis occurs or the fever falls by lysis, 
but the consolidation persists and there may be intense bronchial breath- 
ing, with few or no rales, or the fever may recur and the patient may die 
exhausted. In 1 of my 100 autopsies a patient, aged fifty-eight, had 
died on the thirty-second day from the initial chill. The right lung was 
solid, grayish in color, firm, and presented in places a translucent, semi- 
homogeneous aspect. In these areas the alveolar walls were thickened, and 
the plugs filling the air-cells were undergoing transformation into new 
connective tissue. This fibroid induration may proceed gradually and be 
associated with shrinkage of the affected side, and the gradual production 
of a cirrhosis or chronic interstitial pneumonia. 

Ordinary fibrinous pneumonia never terminates in tuberculosis. The 
instances of caseous pneumonia and softening which have followed an 
acute pneumonic process, have been from the outset tuberculous (see page 
290). 

14. Termination in Abscess. — This occurred in 4 of my 100 autopsies. 
Usually the lung breaks down in limited areas and the abscesses are not 
large, but they may fuse and involve a considerable proportion of a lobe. 
The condition is recognized by the sputum, which is usually abundant and 
contains pus and elastic tissue, sometimes cholesterin crystals and hamia- 
toidin crystals. The cough is often paroxysmal and of great severity; 
usually the fever is remittent, or in protracted cases intermittent in char- 
acter, and there may be pronounced hectic symptoms. "When a case is 
seen for the first time it may be difficult to determine whether it is one 
of abscess of the lung or a local empyaema which has perforated the 
lung. 

15. Gangrene. — This is most commonly seen in old debilitated persons. 
It was present in 3 of my 100 autopsies. It very often occurs with abscess. 
The gangrene is associated with the growth of the saprophytic bacteria on 
a soil made favorable by the presence of the pneumococcus or the strepto- 
coccus. Clinically, the gangrene is rendered very evident by the horriblv 
fetid odor of the expectoration and its characteristic features. In some 
instances the gangrene may be found post-mortem when clinically there 
has not been any evidence of its existence. 



LOBAR PNEUMONIA. 



131 



Prognosis. — Pneumonia is the most fatal of all acute diseases, killing 
more than diphtheria, and outranking even consumption as a cause of death. 

Hospital statistics show that the mortality ranges from 20 to 40 per 
cent. Of 1,012 cases at the Montreal General Hospital, the mortality 
was 20.4 per cent. It appears to be somewhat more fatal in southern 
climates. Of 3,969 cases treated at the Charity Hospital, New Orleans, 
the death-rate was 38.01 per cent. Our mortality at the Johns Hopkins 
Hospital is about 25 per cent in the whites and 30 per cent in the colored. 
In 704 cases at the Pennsylvania Hospital the mortality was 29 per cent. 
At the Boston City Hospital in 1,443 cases the mortality was 29.1 per cent. 
It has been urged that the mortality in this disease has been steadily in- 
creasing, and attempts have been made to connect this increase with the 
expectant plan of treatment at present in vogue. But the careful and thor- 
ough analysis by C. N. Townsend and A. Coolidge, Jr., of 1,000 cases at 
the Massachusetts General Hospital indicates clearly that, when all cir- 
cumstances are taken into consideration, this conclusion is not justified. 
They found that when all fatal cases over fifty years of age were omitted, 
and those patients who were delicate, intemperate, or the subject of some 
complication, there was very little variation from decade to decade, and 
that, excluding these cases, the rate was but little over 10 per cent. In 
answer to the assertion that the modified treatment is in part responsible 
for the increased mortality, these authors show clearly that the rise in 
death-rate took place in the period prior to 1860, when the treatment was 
entirely or in great part heroic. 

According to the analysis of 708 cases at St. Thomas's Hospital by 
Hadden, H. W. G. McKenzie, and W. W. Ord, the mortality progressively 
increases from the twentieth year, rising from 3.7 per cent under that age 
to 22 per cent in the third decade, 30.8 per cent in the fourth, 47 per cent 
in the fifth, 51 per cent in the sixth, 65 per cent in the seventh decade. 
Of 223,730 cases collected by Wells from various sources, 40,276 died, a 
mortality of 18.1 per cent. 

The mortality in private practice varies greatly. E. P. Howard treated 
170 cases with only 6 per cent of deaths. Fussell has recently reported 134 
cases with a mortality of 17.9 per cent. The mortality in children is some- 
times very low. Morrill has recently reported 6 deaths in 123 cases of frank 
pneumonia. On the other hand, Goodhart had 25 deaths in 120 cases. 

The following are among the circumstances which influence the prog- 
nosis: 

Age. — As Sturges remarks, the old are likely to die, the young to re- 
cover. Under one year it is more fatal than between two and five. Fus- 
sell lost 5 out of 8 cases in yearlings. At about sixty the death-rate is very 
high, amounting to 60 or 80 per cent. So fatal is it in this country, at least, 
that one may say that to die of pneumonia is the natural end of old people. 

As already stated, the disease is more fatal in the negro than in the 
white race. 

Previous habits of life and the condition of bodily health at the time 
of the attack form the most important factors in the prognosis of pneu- 
monia. In analyzing a series of fatal cases one is very much impressed with 



132 



SPECIFIC INFECTIOUS DISEASES. 



the number of eases in which the organs show signs of degeneration. In 
25 of my 100 autopsies at the Montreal General Hospital the kidneys 
showed extensive interstitial changes. Individuals debilitated from sick- 
ness or poor food, hard drinkers, and that large class of hospital patients, 
composed of robnst-looking laborers between the ages of forty-five and 
sixty, whose organs show signs of wear and tear, and who have by excesses 
in alcohol weakened the reserve power, fall an easy prey to the disease. 
Very few fatal cases occur in robust, healthy adults. Some of the statistics 
given by army surgeons show better than any others the low mortality from 
pneumonia in healthy picked men. The death-rate in the German army 
in over 40,000 cases was only 3.6 per cent. 

Certain complications and terminations are particularly serious. The 
meningitis of pneumonia is probably always fatal. Endocarditis is ex- 
tremely grave, much more so than pericarditis. Apart from these serious 
complications, the fatal event in pneumonia is due either to a gradual 
toxaemia or to mechanical interference with the respiration and circulation. 

Toxcemia is the important prognostic feature in the disease, to which in 
a majority of the cases the degree of pyrexia and the extent of consolidation 
are entirely subsidiary. It is not at all proportionate to the degree of lung- 
involved. A severe and fatal toxaemia may occur with the consolidation 
of only a small part of one lobe. On the other hand, a patient with com- 
plete solidification of one lung may have no signs of a general infection. 
The question of individual resistance seems to be the most important one, 
and one sees even most robust-looking individuals fatally stricken within 
a few days. 

Much stress has been laid of late upon the factor of leucocytosis as an 
element in the prognosis. A very slight or complete absence of a leuco- 
cytosis is regarded as very unfavorable. Of the 64 cases in my wards 
during the session of 1900-1901 all the low counts were in fatal cases. 
The lowest counts in 5 fatal cases were 1,400, 2,800, 5,000, 2,250, and 3,660. 
As a rule, it may be said that the continuous absence of leucocytosis is 
unfavorable. 

Death from direct interference with the function of respiration is rare. 
It may happen in extensive double pneumonia, but even with involvement 
of a very large section of both lungs recovery may take place. A very im- 
portant element in the prognosis is the condition of the heart, from failure 
of which quite as many die as from the intoxication. The heart weakness 
may be due either to the specific action of the poison, to the prolonged 
fever, or to over-distention of the right chambers. All three factors may 
be at work together. I have already referred to the sudden onset of serious 
cardiac weakness; more commonly there is a gradually increased rapidity 
with increasing weakness of the heart muscle. The pulse is not always a 
safe guide; since, as I mentioned before, it may be full and soft and not 
very rapid within a few hours of a fatal termination, even in cases without 
pronounced toxaemia. 

Diagnosis. — No disease is more readily recognized in a large majority 
of the cases. The external characters, the sputa, and the physical signs 
combine to make one of the clearest of clinical pictures. After a study 



LOBAR PNEUMONIA. 



133 



in the post-mortem room of my own and others' mistakes, I think that 
the ordinary lobar pneumonia of adults is rarely overlooked. Errors are 
])articularly liable to occur in the intercurrent pneumonias, in those com- 
j^licating chronic affections, and in the disease as met with in children, the 
aged, and drunkards. Tuberculo-pneumonic phthisis is frequently con- 
founded with pneumonia. Pleurisy with effusion is, I believe, not often 
mistaken except in children. The diagnostic points will be referred to 
under pleurisy. 

In diabetes, Bright's disease, chronic heart-disease, pulmonary phthisis, 
and cancer, an acute pneumonia often ends the scene, and is frequently 
overlooked. In these cases the temperature is perhaps the best index, 
and should, more particularly if cough develops, lead to a careful examina- 
tion of the lungs. The absence of expectoration and of pulmonary symp- 
toms may make the diagnosis very difficult. 

In children there are two special sources of error; the disease may be 
entirely masked by the cerebral symptoms and the case mistaken for one 
of meningitis. It is remarkable in these cases how few indications there 
are of pulmonary trouble. The other condition is pleurisy with effusion, 
which in children often has deceptive physical signs. The breathing may 
be intensely tubular and tactile fremitus may be present. The exploratory 
needle is sometimes required to decide the question. In the old and de- 
bilitated a knowledge that the onset of pneumonia is insidious, and that 
the symptoms are ill-defined and latent, should put the practitioner on his 
guard and make him very careful in the examination of the lungs in doubt- 
ful cases. In chronic alcoholism the cerebral symptoms may predominate 
and completely mask the local process. As mentioned, the disease may 
assume the form of violent mania, but more commonly the symptoms are 
those of delirium tremens. In any case rapid pulse, rapid respiration, and 
fever are symptoms which should invariably excite suspicion of inflamma- 
tion of the lungs. Under cerebro-spinal meningitis will be found the points 
of differential diagnosis between pneumonia and that disease. 

Pneumonia is rarely confounded with ordinary consumption, but to 
differentiate acute tuberculo-pneumonic phthisis is often difficult. The 
case may set in with a chill. It may be impossible to determine which 
condition is present until softening occurs and. elastic tissue and tubercle 
bacilli appear in the sputum. A similar mistake is sometimes made in 
children. With typhoid fever, pneumonia is not infrequently confounded. 
There are instances of pneumonia with the local signs well marked in 
which the patient rapidly sinks into what is known as the typhoid stale 
with dry tongue, rapid pulse, and diarrhoea. Unless the case is seen from 
the outset it may be very difficult to determine the true nature of the 
malady. On the other hand, there are cases of typhoid fever which set in 
with symptoms of lobar pneumonia — the so-called pneumo-typhus. II may 
be impossible to make a differential diagnosis in such a ease unless the 
characteristic eruption develops or the Widal reaction be found. 

Prophylaxis. — The question of the prevention of pneumonia is a 
difficult one, which has hardly yet come within the sphere of practical 
knowledge. More care should be taken with pneumonic sputum than has 



134 



SPECIFIC INFECTIOUS DISEASES. 



been done heretofore, and it should be carefully disinfected. Individuals 
who have had pneumonia should be specially careful to keep the mouth 
and throat thoroughly cleansed, and any house in which several cases of 
pneumonia have occurred in rapid succession should be thoroughly dis- 
infected. 

Treatment. — Pneumonia is a self -limited disease, which can neither 
be aborted nor cut short by any known means at our command. Even 
under the most unfavorable circumstances it may terminate abruptly and 
naturally, without a dose of medicine having been administered. A patient 
was admitted into the Philadelphia Hospital on the evening of the seventh 
day after the chill, in which he had been seen by one of my assistants, who 
had ordered him to go to a hospital. He remained, however, in his house 
alone, without assistance, taking nothing but a little milk and bread and 
whisky, and was brought into the hospital by the police in a condition of 
active delirium. That night his temperature was 105° and his pulse above 
120. In his delirium he came near escaping through the window of the 
ward. The following morning — the eighth day — the crisis occurred, and 
at ward class his temperature was below 98°. The entire lower lobe of the 
right side was found involved, and he entered upon a rapid convalescence. 
So also, under the favoring circumstances of good nursing and careful 
diet, the experience of many physicians in different lands has shown that 
pneumonia runs its course in a definite time, terminating sometimes spon- 
taneously on the third or the fifth day, or continuing until the tenth or 
twelfth. 

There is no specific treatment for pneumonia. The young practitioner 
may bear in mind that patients are more often damaged than helped by 
the promiscuous drugging, which is still only too prevalent. 

1. General Management of a Case. — The same careful hygiene of the 
bed and of the sick-room should be carried out as in typhoid fever. The 
patient should not be too much bundled up with clothing. For the heavy 
flannel undershirts should be substituted a thin, light flannel jacket, open 
in front, which enables the physician to make his examinations without 
unnecessarily disturbing the patient. The room should be bright and 
light, letting in the sunshine if possible, and thoroughly well ventilated. 
Only one or two persons should be allowed in the room at a time. Even 
when not called for on account of the high fever, the patient should be 
carefully sponged each day with tepid water. This should be done with 
as little disturbance as possible. Special care should be taken to keep the 
mouth and gums cleansed. 

2. Diet. — Plain water, a pleasant table water, or lemonade should be 
given freely. When the patient is delirious the water should be given at 
fixed intervals. The food should be liquid, consisting chiefly of milk, 
either alone or, better, mixed with food prepared from some one of the 
cereals, and eggs, either soft boiled or raw. 

3. Special Treatment. — Certain measures are believed to have an influ- 
ence in arresting, controlling, or cutting short the disease. It is very diffi- 
cult for the practitioner to arrive at satisfactory conclusions on this ques- 
tion in a disease so singularly variable in its course. How natural, when 



LOBAR PNEUMONIA. 



135 



on the third or fourth day the crisis occurs and convalescence sets in, to 
attribute the happy result to the effect of some special medication! How 
easy to forget that the same unexpected early recoveries occur under 
other conditions! The following are among the measures which may be 
helpful: 

(a) Bleeding. — The reproach of Van Helmont, that " a bloody Moloch 
presides in the chairs of medicine/' can not be brought against this gen- 
eration of physicians. Before Louis' iconoclastic paper on bleeding in 
pneumonia it would have been regarded as almost criminal to treat a case 
without venesection. We employ it nowadays much more than we did 
a few years ago, but more often late in the disease than early. To bleed 
at the very onset in robust, healthy individuals in whom the disease sets 
in with great intensity and high fever is, I believe, a good practice. I have 
seen instances in which it was very beneficial in relieving the pain and the 
dyspnoea, reducing the temperature, and allaying the cerebral symptoms. 

(b) Drugs. — Certain drugs are credited with the power of reducing the 
intensity and shortening the duration of the attack. Among them vera- 
trum viride still holds a place, doses of 1\[ ii-v of the tincture given every 
two hours. Tartar emetic — a remedy which had great vogue some years 
ago — is now very rarely employed. To a third drug, digitalis, has been 
attributed of late great power in controlling the course of the disease. 
Petresco gives at one time as much as from 4 to 12 grammes of the pow- 
dered leaves, and claims that these colossal doses are specially efficacious 
in shortening the course of the disease and diminishing the mortality. 

(c) Antipneumonic Serum. — Note the remark on p. 112. The Klemp- 
erer brothers, Auld, Washbourn, and others have reported favorable re- 
sults. The serum is injected into the subcutaneous tissues. Washbourn 
recommends as a dose 20 cc, and thinks it is well to make an injection 
twice a day until the patient is convalescent. Of 141 cases treated with 
antipneumonic serum, collected by G-. E. Tyler, only 20 died. 

4. Symptomatic Treatment. — (a) To relieve the Pain. — The stitch in 
the side at onset, which is sometimes so agonizing, is best relieved by a 
hypodermic injection of a quarter of a grain of morphia. When the pain 
is less intense and diffuse over one side, the Paquelin cautery applied lightly 
is very efficacious, or hot or cold applications may be tried. When the dis- 
ease is fairly established the pain is not, as a rule, distressing, except when 
the patient coughs, and for this the Dover's powder may be used in 5-grain 
doses, according to the patient's needs. Hot poultices, formerly so much 
in use, relieve the pain, though not more than the cold applications. For 
children they are often preferable. 

(b) To combat the Toxcemia. — Herein lies our chief weakness in dealing 
with pneumonia. We have as yet no specific, either drug or the product of 
the bacteriological laboratory, which safely and surely neutralizes the 
poison of the disease. We may reasonably hope that such a remedy ere 
long will be forthcoming, but meantime we must be content with measures 
which aim at keeping up the strength of the patient. The saline infusions 
aid in the elimination of the poison. 

(c) The third and all-important indication in the treatment of pneu- 



136 



SPECIFIC INFECTIOUS DISEASES. 



mania is to support the heart. The practitioner must ever be on the alert 
to prevent the onset of cardiac weakness, and to treat it should that con- 
dition arise. 

To prevent the Onset of Cardiac Weakness. — We can not at present sepa- 
rate the effects of the fever from those of the poisons circulating in the 
blood. It is possible, indeed, as some suppose, that the fever itself may 
be beneficial. Undoubtedly, however, high and prolonged pyrexia is dan- 
gerous to the heart, and should be combated. For this our most trusty 
weapon is hydrotherapy, which in pneumonia is used in several different 
ways. The ice-bag to the affected side is one of the most convenient and 
serviceable. Its good effects have been strongly insisted upon by Mays. I 
have used ice systematically in my wards for the past ten years. It allays 
the pain, reduces the fever slightly, and, as a rule, the patient sa}^s he 
feels very much more comfortable. Broad, flat ice-bags are now easily 
obtained for the purpose, and if these are not available an ice poultice can 
be readily made, and by the use of oil-silk the clothing and bedding of 
the patient can be protected from the water. Cold sponging is the best 
form of hydrotherapy to employ as a routine measure. When done limb 
by limb the patient is but little disturbed, and it is refreshing and bene- 
ficial. With very pronounced nervous symptoms and persistent high 
temperature, or with hyperpyrexia^ a cold bath of ten minutes' dura- 
tion may be given. Von Jurgensen, one of the best of living students 
of the disease, strongly advises it under these conditions. Personally, 
my experience with the full cold bath is not large enough to enable me 
to express a positive opinion. In this country we have not, I think, used 
it sufficiently in the toxic cases, in which in typhoid fever we see such 
good results. 

Of medicinal antipyretics, quinine has been much vaunted in doses of 
from 30 to 60 grains daily. Unfortunately, it is apt to disturb the stomach 
and cause unpleasant ringing in the ears; according to some, also, it is very 
depressing, but I must say I have never seen any injurious effects from it, 
though I have not used it for some years. Antipyrin, antifebrin, and 
phenacetin have been thoroughly tried in pneumonia, and the general opin- 
ion at present is decidedly against their systematic employment. 

Alcohol may be used with benefit in a majority of cases of pneumonia. 
In moderate doses it diminishes slightly the temperature, increases the 
appetite, obviates the tendency to heart weakness, and is a conservator 
of energy, being itself consumed in supplying heat in place of the body 
tissues. Two or three ounces of good whisky in the twenty-four hours 
may be used in the case of old and debilitated patients. 

To treat Heart Weakness when Present. — Now the resources and judg- 
ment of the phvsician are taxed to the utmost. Is the heart weakness due 
to progressive distention and overfilling of the right heart? This is 
usually indicated by increasing cyanosis, increasing shortness of breath, 
signs of cedematous infiltration in the uninvolved parts of the lung, and a 
small and feeble radial pulse. Under these circumstances a free venesection 
is sometimes helpful, though I must say that my personal experience has 
not been very satisfactory. I have, however, within the past few years 



LOBAR PNEUMONIA. 



137 



seen several cases in which it seemed to be timely, even life-saving. Too 
often the progressive cardiac asthenia is due to the action of the fever and 
of the poisons, partly upon the heart muscle itself, partly upon the nerve 
centres, cardiac and respiratory. An increase in the amount of alcohol is 
advisable when the pulse becomes small, frequent, and feeble or very com- 
pressible, and when the heart-sounds, particularly the second pulmonic, 
begin to lose their force. The amount will vary with the age of the pa- 
tient and with his habits. It may be increased, if necessary, to 12 or 16 
ounces in the twenty-four hours. Strychnia is a most valuable cardiac 
tonic in pneumonia. It may be given in doses of from one sixtieth to one 
thirtieth of a grain hypodermically, or, if the heart's action becomes more 
feeble, in still larger doses, up to one twentieth or even one twelfth of a 
grain every three or four hours. Digitalis is indicated with the earliest 
signs of cardiac weakness. If the heart's action becomes very rapid, or if, 
as above stated, there is a sudden onset of cardiac weakness, indicated by 
a very quick and irregular pulse, it may be given freely, either, in the form 
of the tincture, 15 or 20 minims every two hours until 2 drachms are given, 
or a digitalin hypodermically in doses of from a thirtieth to a twentieth of 
a grain every three hours. Other remedies still much in use are the aro- 
matic spirits of ammonia, camphor, musk, and the hypodermic injections 
of ether. Two other measures may be referred to under this section. 

Oxygen Gas. — It is doubtful whether the inhalation of oxygen in pneu- 
monia is really beneficial. The work of Lorrain-Smith suggests, indeed, 
that it may under certain circumstances be positively harmful. He has 
shown experimentally that oxygen may be a serious irritant, actually pro- 
ducing inflammation of the lungs. If we are justified in applying his results 
to man, there can be but little doubt that the administration of oxygen 
may not be entirely " harmless," as stated in the last edition of this work. 
If the tension of the oxygen breathed rises to 80 per cent of an atmosphere, 
which it might easily do in certain methods of administration, it may be 
injurious. When used it should be allowed to flow gently from the nozzle 
held at a little distance, in which way it is freely diluted with air. 

Saline injections hypodermically have been much used, and certainly do 
good in helping to tide over a critical period of cardiac depression. As 
much as a couple of pints may be allowed to run beneath the skin by grav- 
ity, a rubber bag and either a large hypodermic or a middle-sized aspirator 
needle being used. The injection may be made in the flanks or in the 
thighs. Our experience of the past three years is decidedly favorable to 
the use of saline infusions in the disease. 

Treatment of Complications. — If the fever persists it is important to 
look out for pleurisy, particularly for the meta-pneumonic empyema. The 
exploratory needle should be used if necessary. A sero-fibrinous effusion 
should be aspirated, a purulent opened and drained. In a compliniting 
pericarditis with a large effusion aspiration may be necessary. Delayed 
resolution is a difficult condition to treat. Hiess has recommended pilo- 
carpine, which I have tried in one or two cases without much benefit. 



138 



SPECIFIC INFECTIOUS DISEASES. 



XVI. DIPHTHERIA. 

Definition. — A specific infectious disease, characterized by a local 
fibrinous exudate, usually upon a mucous membrane, and by constitutional 
symptoms due to toxins produced at the site of the lesion. The presence 
of the Klebs-Loeffler bacillus is the etiological criterion by which true 
diphtheria is distinguished from other forms of membranous inflamma- 
tion. 

The clinical and bacteriological conceptions of diphtheria are at present 
not in full accord. On the one hand, there are cases of simple sore throat 
which the bacteriologists, finding the Klebs-Loeffler bacillus, call true 
diphtheria. On the other hand, cases of membranous, sloughing angina, 
diagnosed by the physician as diphtheria, are called by the bacteriologists, 
in the absence of the Klebs-Loeffler bacillus, pseudo-diphtheria or diph- 
theroid angina. 

The term diphtheroid may be used for the present to designate those 
forms in which the Klebs-Loeffler bacillus is not present. Though usually 
milder, severe constitutional disturbance, and even paralysis, may follow 
these so-called pseudo-diphtheritic processes. 

Historical Note. — The disease was known to Aretaeus and to Galen. 
Epidemics occurred throughout the middle ages. It appeared early among 
the settlers of New England, and accounts are extant of epidemics in this 
country in the seventeenth and eighteenth centuries. Huxham and Fother- 
gill gave excellent descriptions of the disease. An admirable account was 
given by Samuel Bard,* of New York, whose essay is one of the most solid 
contributions made to medicine in America. It was reserved for Pierre 
Bretonneau, of Tours, to grasp the fact that angina suffocativa, " cynanche 
maligna" the "putrid/' and other forms of malignant sore throat, were 
one and the same disease, to which he gave the name " diphlheriie" 

Etiology.' — The disease is endemic in the larger centres of population, 
and becomes epidemic at certain seasons of the year. While other con- 
tagious diseases have diminished within the past decade, diphtheria has in- 
creased, particularly in cities. It has prevailed also with great severity in 
country districts, in which indeed the affection seems to be specially viru- 
lent. A close relation between imperfect drainage or a polluted water- 
supply and diphtheria has not been determined. 

Diphtheria is a highly contagious disease, readily communicated from 
person to person. The bacilli may be received, " (1) from the membranous 
exudate or discharges from diphtheria patients; (2) from the secretions 
of the nose and throat of convalescent cases of diphtheria in which the 
virulent bacilli persist; (3) from the throats of healthy individuals who 
have acquired the bacilli from being in contact with others having virulent 
germs on their person or clothing: in such cases the bacilli may sometimes 
live and develop for days or weeks in the throat without causing any lesion " 
(Park and Beebe). In the tenement districts of New York these authors 
recognized two varieties of local epidemics. In one, the cases were evi- 



* Transactions of the American Philosophical Society, vol. i, Philadelphia, 1770. 



DIPHTHERIA. 



139 



dently from neighborhood infection; while in the other, the infection was 
derived from schools, since a whole district would suddenly become the 
seat of scattered cases. " At times in a certain area of the city, from which 
several schools drew their scholars, all the cases of diphtheria would occur 
(as investigation showed) in families whose children attended one school, 
the children of the other schools being for the time exempt." 

No disease of temperate regions proves more fatal to physicians and 
nurses. There seems to be particular danger in the examination and swab- 
bing of the throat, for in the gagging, coughing, and spluttering efforts 
the patient may cough mucus and flakes of membrane into the physician's 
face. The virus attaches itself to the clothing, the bedding, and the room 
in which the patient has lived, and has in many instances displayed great 
tenacity. It has been found to live on blood serum for one hundred and 
fifty-five days, in gelatin for eighteen months, dried on silk threads for one 
hundred and seventy-two days, on a child's plaything which had been kept 
in a dark place for five months, and in bits of dried membrane for from 
fourteen to twenty weeks. An instance has been reported (Golay) in which 
the bacilli were present in the throat for three hundred and sixty-two days. 
During this period there were three acute relapses. They have been found, 
too, in the dust of a diphtheria pavilion, and in the hair and clothing of 
the nurses in attendance upon diphtheria babies (Wright and Emerson). 
Forbes isolated diphtheria bacilli from a vessel which was regarded as the 
cause of the disease in twenty-four families. The bacilli grow readily in 
milk without changing its appearance. From cheese which was made on 
a farm on which diphtheria prevailed, pure cultures of diphtheria bacilli 
were obtained (New York Board of Health Eeport, 1894). 

The disease may be transmitted by inoculation. 

Calves, cats, and fowls are subject to contagious membranous diseases, 
which are, however, not identical with diphtheria in man and are not com- 
municable to him. 

As in other infectious disorders, individual susceptibility plays an im- 
portant role. Not only do very many of those exposed escape, but even of 
those in whose throats the bacilli lodge and grow. 

Of predisposing causes age is one of the most important. Very young 
children are rarely attacked, but Jacobi states that he has seen three in- 
stances of the disease in the newly born. Between the second and the fif- 
teenth year a large majority of the cases occur. In this period the greatest 
number of deaths is between the second and the fifth years. Girls are 
attacked in larger numbers than boys, probably because they are brought 
into closer contact with the sick. Adults are frequently affected. The 
disease is most prevalent in the cold autumn weather. The secondary 
pseudo-membranous inflammations, caused usually by the streptococcus, 
attack debilitated persons, the subjects of fevers, particularly of scarlet 
fever, typhoid, and measles. 

Caille regards as special predisposing elements in children enlarged 
tonsils, chronic naso-pharyngeal catarrh, carious teeth, and an unhealthy 
condition of the mucous membrane of the mouth and throat. 

Epidemics vary in intensity. While in some the affection is mild and 



140 



SPECIFIC INFECTIOUS DISEASES. 



rarely fatal, in others it is characterized by wide extension of the mem- 
brane, and shows a special tendency to attack the larynx. 

The Klebs-Loeffler bacillus occurs in a large percentage of all 
snspected cases. It is found chiefly in the false membrane, and does not 
extend into the subjacent mucosa. In the majority of instances the organ- 
isms are localized, and only a few penetrate into the interior. In many 
instances the bacilli are found in the blood and in the internal organs. 
It may be the predominating or sole organism in the broncho-pneu- 
monia so common in the disease. Outside the throat, the common site 
of its morbid action, the Klebs-Loeffler bacillus has been found in diph- 
theritic conjunctivitis, in otitis media, sometimes in wound diphtheria, in 
fibrinous rhinitis, and in an attenuated condition by Howard in a case of 
ulcerative endocarditis. 

Morphological Characters. — The bacillus is non-motile, varies from 2.5 
to 3 juu in length, and from 0.5 to 0.8 in thickness. It appears as a straight 
or slightly bent rod with rounded ends; irregular, bizarre forms, such as 
rods with one or both ends swollen and simple branching forms, are more 
or less common. The bacillus stains in sections or on the cover-glass by 
the Gram method. 

It grows best upon a mixture of glucose bouillon and blood serum 
(Loeffler), forming large, elevated, grayish-white colonies with opaque cen- 
tres. It grows also upon all the ordinary culture media. The growth 
usually ceases at temperatures below 20° C. 

The bacillus is very resistant, and cultures have been made from a bit 
of membrane preserved for five months in a dry cloth. Incorporated with 
dust and kept moist, the bacilli were still cultivatable at the end of eight 
weeks; kept in a dried state they no longer grew at the end of this period 
(Bitter). 

Variation in Virulence. — For testing the virulence the guinea-pig is 
used, being most susceptible to the poison. An amount of a forty-eight 
hour bouillon culture equalling one half per cent of the weight of the ani- 
mal is injected subcutaneously. "A fully virulent culture is one which 
causes the death of a guinea-pig within three days or less; a culture of 
medium virulence one which causes the death of the animal in from three to 
five days. Cultures which only produce local necrosis and ulceration or death 
after a greater number of days may be considered as of slight virulence " 
(J. H. Wright). At the seat of the inoculation there is local necrosis with 
fibrinous exudate which contains the bacilli, and there is also a more or 
less extensive oedema of the subcutaneous tissue. The Klebs-Loeffler 
bacillus evidently has very varying grades of virulence down even to com- 
plete absence of pathogenic effects. The name pseudo-bacillus of diph- 
theria should not be given to this avirulent organism. 

The Presence of the Klebs-Loeffler Bacillus in Non-membranous Angina 
and in Healthy Throats. — The bacillus has been isolated from cases which 
show nothing more than a simple catarrhal angina, of a mild type without 
any membrane, with diffuse redness, and perhaps huskiness and signs of 
catarrhal laryngitis. In other cases the anatomical picture may be that of 
a lacunar tonsillitis. 



DIPHTHERIA. 



141 



The organisms may be met with in perfectly healthy throats, particu- 
larly in persons in the same house, or the ward attendants and nurses in 
fever hospitals. 

Following an attack of diphtheria the bacilli may persist in the throat 
or nose after all the membrane has disappeared for weeks or months — even 
15 months. In explanation of this persistence Councilman has called at- 
tention to the frequency with which the antrum is affected. 

Toxine of the Klebs-Loeffler Bacillus. — Eoux and Yersin showed that 
a fatal result following the inoculation with the bacillus was not caused 
by any extension of the micro-organisms within the body; and they were 
enabled in bouillon cultures to separate the bacilli from the poison. The 
toxine so separated killed with very much the same effects as those caused 
by the inoculation of the bacilli; the pseudo-membrane, however, is not 
formed. These results were confirmed by many observers, particularly by 
Sidney Martin, who separated a toxic albumose. The precise composition 
of the body and whether it is a proteid at all is still doubtful. 

Susceptible animals may be rendered immune from diphtheritic in- 
fection by injecting weakened cultures of the bacillus or, what is better, 
suitable doses of the diphtheria toxine. The result of the injections is 
a febrile reaction which soon passes away and leaves the animal less sus- 
ceptible to the poison or the living bacilli. By repeating and gradually 
increasing the quantity of poison injected a high degree of immunity can 
be produced in large animals (goat, horse). 

The Bacteria associated with the Diphtheria Bacillus. — The most com- 
mon is the streptococcus pyogenes. Others, in addition to the organisms 
constantly found in the mouth, are the micrococcus lanceolatus, the ba- 
cillus coli communis, and the staphylococcus aureus and albus. Of these, 
probably the streptococcus pyogenes is the most important, as cases of 
general infection with this organism have been found in diphtheria. The 
suppuration in the lymph-glands and the broncho-pneumonia are usually 
(though not always) caused by this organism. 

Pseudo-Diphtheria Bacillus. — Bacillus Xerosis. — As mentioned above, 
the Klebs-Loeffler bacillus varies very much in its virulence, and it exists 
in a form entirely devoid of pathogenic properties. This organism should 
not, however, be designated pseudo-diphtheria bacillus. The name should 
be confined to bacilli, which, though resembling the diphtheria bacillus, 
differ from it not only by absence of virulence, but also by cultural pecul- 
iarities. A similar bacillus, showing, however, certain cultural differ- 
ences from the pseudo-diphtheria bacillus, has been repeatedly found in 
the conjunctival sac in health and disease (B. xerosis). Organisms having 
the morphology of the diphtheria bacillus, but devoid of virulence, probably 
belonging to the group of pseudo-diphtheria and xerosis bacilli, have been 
described in human beings in association with a number of diseases, such 
as Egyptian dysentery (Kruse and Pasquale); they have been demonstrated 
upon the skin, in the crusts of variola pustules, and in impetigo, in sputum, 
in pneumonia (Kruse, Ohlmaeher), in gangrene of the lung (Babes), in 
ulcerative endocarditis (Howard), in ascitic fluid (Harris), in pus from 
pyuria (Bergly), in ozsena (Wilder), and in tuberculosis (Schultz and Ehret). 
Both the pseudo-diphtheria and xerosis bacilli show occasional branchings. 



142 



SPECIFIC INFECTIOUS DISEASES. 



Diphtheroid Inflammations. — Under the term diphtheroid may 
be grouped those membranous inflammations which are not associated with 
the Klebs-Loeffler bacillus. It is perhaps a more suitable designation than 
pseudo-diphtheria or secondary diphtheria. As in a great majority of cases 
the streptococcus pyogenes is the active organism, the term " streptococcus 
diphtheritis " is often employed. The name " diphtheritis " is best used in 
an anatomical sense to designate an inflammation of a mucous membrane 
or integumentary surface characterized by necrosis and a fibrinous exudate, 
whereas the term " diphtheria " should be limited to the disease caused by 
the Klebs-Loeffler bacillus. The proportion of cases of diphtheroid in- 
flammation varies greatly in the different statistics. Of the large number 
of observations made by Park and Beebe (5,611) in New York, 40 per cent 
were diphtheroid. Figures from other sources do not show so high a per- 
centage. 

It is not to be inferred from these statistics that any considerable num- 
ber of the cases which present the appearances of typical and characteristic 
primary diphtheria are due to other micro-organisms than the Klebs- 
Loeffler bacillus. Nearly all such cases, when carefully examined by a com- 
petent bacteriologist, are found to be due to the diphtheria bacillus. It 
is the less characteristic cases, with more or less suspicion of diphtheria, 
which are most likely to be caused by other bacteria than the Klebs- 
Loeffler bacillus. It is also to be remembered that in the routine exam- 
ination of a large number of cases for boards of health and diphtheria 
wards of hospitals, some cases of genuine diphtheria may escape recog- 
nition from lack of such repeated and thorough bacteriological tests as are 
sometimes required for the detection of cases presenting unusual diffi- 
culties. 

Conditions under which the Diphtheroid Affection occurs. — Of 450 cases 
(Park and Beebe), 300 occurred in the autumn months and 150 in the 
spring; 198 occurred in children from the first to the seventh year. In a 
large proportion of all the cases the disease develops in children, and can 
only be differentiated from diphtheria proper by the bacteriological ex- 
amination. In many of the cases it is simply an acute catarrhal angina 
with lacunar tonsillitis. 

The diphtheroid inflammations are particularly prone to develop in 
connection with the acute fevers. 

(a) Scarlet Fever. — In a large proportion of the cases of angina in scar- 
let fever the Klebs-Loeffler bacillus is not present. Booker has reported 
11 cases complicating scarlet fever, in all of which the streptococci were 
the predominant organisms. Of the 450 cases of Park and Beebe, 42 com- 
plicated scarlet fever. The angina of this disease is not always, however, 
due to the streptococcus. Where diphtheria is prevalent and opportunities 
are favorable for exposure, a large proportion of the cases of membranous 
throats in scarlet fever may be genuine diphtheria, as is shown by the sta- 
tistics of Williams and Morse in the Boston City Hospital. Here, of 97 
cases of scarlet fever, membranous angina was present in 35; in 12 with 
the Klebs-Loeffler bacillus, and in 23 with other organisms. Morse reports 
99 cases of angina in scarlet fever in which 76 were diphtheritic. This 



DIPHTHEEIA. 



143 



large proportion of cases in which scarlet fever was associated with true 
diphtheria is attributed to local conditions in the hospital. 

(b) Measles. — Membranous angina is much less common in this disease. 
It occurred in 6 of the 450 diphtheroid cases in New York. Of 4 cases 
with severe membranous angina at the Boston City Hospital, 1 only pre- 
sented the Klebs-Loefner bacillus. 

(c) Whooping-cough may also be complicated with membranous angina. 
The bacteriological examinations have not been very numerous. Escherich 
gives 4 cases, in all of which the Klebs-Loefner bacillus was found. 

(d) Typhoid Fever. — Membranous inflammations in this disease are not 
very infrequent; they may occur in the throat, the pelvis of the kidney, 
the bladder, or the intestines. The complication may be caused by the 
Klebs-Loefner bacillus, which was present in 4 cases described by Morse. 
It is frequently, however, a streptococcus infection. 

Ernst Wagner has remarked upon the greater frequency of these mem- 
branous inflammations in typhoid fever when diphtheria is prevailing. 

Clinical Features of the Diphtheroid Affection. — The cases, as a rule, 
are milder, and the mortality is low, only 2.5 per cent in the 450 cases of 
Park and Beebe. The diphtheroid inflammations complicating the specific 
fevers are, however, often very fatal, and a general streptococcus infection 
is by no means infrequent. As in the Klebs-Loefner angina, there may 
be only a simple catarrhal process. In other instances the tonsils are cov- 
ered with a creamy, pultaceous exudate, without any actual membrane. 
An important group may begin as a simple lacunar tonsillitis, while in 
others the entire fauces and tonsils are covered by a continuous membrane, 
and there is a foul sloughing angina with intense constitutional disturb- 
ance. 

Are the diphtheroid cases contagious? General clinical experience war- 
rants the statement that the membranous angina associated with the fevers 
is rarely communicated to other patients. The health department of New 
York does not keep the diphtheroid cases under supervision. Their inves- 
tigation of the 450 diphtheroid cases seems to justify this conclusion. Park 
and Beebe say that " it did not seem that the secondary cases were any less 
liable to occur when the primary case was isolated than when it was not." 

Sequelce of the Diphtheroid Angina. — The usual mildness of the disease 
is in part, no doubt, due to the less frequent systemic invasion. Some of 
the worst forms of general streptococcus infection are, however, seen in 
this disease. There are no peculiarities, local or general, which can be in 
any way regarded as distinctive; and if the observation of Bourges should 
be corroborated, even the most extensive paralysis may follow an angina 
caused by it. 

Morbid Anatomy. — Distribution of Membrane. — A definite mem- 
brane was found in 127 of the 220 fatal Boston cases, distributed as follows: 
tonsils, 65 cases; epiglottis, 60; larynx, 75; trachea, 66; pharynx, 51; mu- 
cous membrane of nares, 43; bronchi, 42; soft palate, including uvula, 13; 
oesophagus, 12; tongue, 9; stomach, 5; duodenum, 1; vagina, 2; vulva, 1; 
skin of ear, 1; conjunctiva, 1. An interesting point in the Boston in- 
vestigation was the great frequency with which the accessory sinuses 
of the nose were found to be infected. In the fatal cases, the exuda- 



1U 



SPECIFIC INFECTIOUS DISEASES. 



tion is very extensive, involving the uvula, the soft palate, the posterior 
nares, and the lateral and posterior walls of the pharynx. These parts are 
covered with a dense pseudo-membrane, in places firmly adherent, in others 
beginning to separate. In extreme cases the necrosis is advanced and 
there is a gangrenous condition of the parts. The membrane is of a dirty 
greenish or gray color, and the tonsils and palate may be in a state of 
necrotic sloughing. The erosion may be deep enough in the tonsils to 
open the carotid artery, or a false aneurism may be produced in the deep 
tissues of the neck. The nose may be completely blocked by the false mem- 
brane, which may also extend into the conjunctivae and through the 
Eustachian tubes into the middle ear. In cases of laryngeal diphtheria 
the exudate in the pharynx may be extensive. In many cases, however, it 
is slight upon the tonsils and fauces and abundant upon the epiglottis and 
the larynx, which may be completely occluded by false membrane. In 
severe cases the exudate extends into the trachea and to the bronchi of 
the third or fourth dimension. This occurred in nearly half of my 30 
Montreal autopsies. 

In all these situations the membrane varies very much in consistence, 
depending greatly upon the stage at which death has taken place. If death 
has occurred early, it is firm and closely adherent; if late, it is soft, shreddy, 
and readily detached. When firmly adherent it is torn off with difficulty 
and leaves an abraded mucosa. In the most extreme cases, in which there 
is extensive necrosis, the parts look gangrenous. In fatal cases the lym- 
phatic glands of the neck are enlarged, and there is a general infiltration 
of the tissues with serum; the salivary glands, too, may be swollen. In 
rare instances the membrane extends to the gullet and stomach. 

On inspection of the larynx of a child dead of membranous croup, the 
rima is seen filled with mucus or with a shreddy material which, when 
washed off carefully, leaves the mucosa covered by a thin grayish-yellow 
membrane, which may be uniform or in patches. It covers the ary-epi- 
glottic folds and the true cords, and may be continued into the ventricles 
or even into the trachea. Above, it may involve the epiglottis. It varies 
much in consistency. I have seen fatal cases in which the exudation was 
not actually membranous, but rather friable and granular. It may form 
a thick, even stratified membrane, which fills the entire glottis. The ex- 
udation may extend down the trachea and into the bronchi, and may pass 
beyond the epiglottis to the fauces. Usually it is readily stripped off from 
the mucous membrane of the larynx and leaves exposed the swollen and 
injected mucosa. On examination it is seen that the fibrinous material 
has involved chiefly the epithelial lining and has not greatly infiltrated the 
subjacent tissues. 

Histological Changes. — We owe largely to the labors of Wagner, Wei- 
gert, and more particularly to the splendid work of Oertel, our knowledge 
of the minute changes which take place in diphtheria. The following is 
a brief abstract of the recent studies of Councilman, Mallory, and Pearce: 

The beginning of the lesion is due to the toxic action of the bacilli 
growing in the throat. The primary lesion is a necrosis and degeneration 
of the epithelial tissues. The organisms grow, not in the living, but in 



DIPHTHERIA. 



145 



the necrotic tissues. The first step is necrosis of the epithelium, often pre- 
ceded by active proliferation of the nuclei of the cells, which become 
changed into refractive hyaline masses. From the structures below an 
inflammatory exudate rich in fibrin factors is poured out, and fibrin is 
formed when this comes in contact with the necrotic epithelium. " The 
fibrin in part is formed into a reticulum around exudation cells and 
degenerated epithelium; in part it combines with the hyaline degen- 
erated cells to form a hyaline membrane. It is probable that a hya- 
line membrane may be formed without the exudation; in this case the 
network of the membrane represents the edges of the cells, and the 
spaces the former nuclei. The hyaline membrane is most often formed on 
those surfaces which are covered with epithelium having several layers of 
cells. ... It is probable that the fibrinous membrane is formed both on 
the surfaces and in the tissue. The fibrin is first formed around cells which 
afterward disappear. The membrane may disintegrate and be broken up 
into a mass of detritus (the process commences on the surface), or it may be 
cast off as a whole by being elevated by an exudation beneath. Very thick 
masses of membrane may be formed by the constant addition of fibrinous 
exudation. The membrane is never formed primarily on an intact epi- 
thelial surface, but it may extend over it. . . . The connective tissue and 
blood-vessels undergo a hyaline fibrinoid degeneration very similar to the 
degeneration of the epithelium. Necrosis may extend deeply into the 
tissue, but there is little tendency to deep ulceration or abscess formation. 
The degeneration in the mucous glands of the tissue is so pronounced as to 
be almost specific." 

The following are the important changes in the other organs: 
Heart. — Fatty degeneration is found in a majority of the cases. It may 
precede the more advanced degeneration, in which the sarcous elements 
become swollen and converted into hyaline masses. There is a primary, 
acute, interstitial myositis, and also a form secondary to degeneration of the 
heart muscle, to which it is possible that some of the cases of fibrous myo- 
carditis are due. Pericarditis and endocarditis are rare; endocarditis was 
present in 7 of 220 cases at the Boston City Hospital. The diphtheria 
bacilli have been found in the vegetations by W. T. Howard, Jr., and by 
J. W. Wright. 

The pulmonary complications are the most important, and death is due 
to them as often as to the throat lesion. Broncho-pneumonia, or, as Coun- 
cilman terms it, acinous pneumonia, is the most common, and was present 
in 131 of the 220 Boston cases. Acute lobar pneumonia is rare. The 
pneumococcus is the principal agent in producing the lung infection. The 
streptococci and the diphtheria bacilli are frequently met with. 

Kidneys. — The lesions, which are duo to the action of the toxins, not 
to the presence of bacteria, vary from simple degeneration to an intense 
nephritis. There is no specific type of lesion. Interstitial and glomerular 
nephritis are most common in the older subjects. Degenerative changes 
are present in a large proportion of all the fatal cases. 

The liver and the spleen show the degenerative lesions of the acute 
infections. 

General infection is common, and is about equal with the strepto- 



146 



SPECIFIC INFECTIOUS DISEASES. 



coccus and the diphtheria bacillus. It occurs generally in the grave septic 
cases, in which type of cases the former organism is more frequently met 
with. 

Symptoms. — The period of incubation is " from two to seven days, 
oftenest two." 

The initial symptoms are those of an ordinary febrile attack — slight 
chilliness, fever, and aching pains in the back and limbs. In mild cases 
these symptoms are trifling, and the child may not feel ill enough to go 
to bed. Usually the temperature rises within the first twenty-four hours 
to 102.5° or 103°; in severe cases to 104°. In young children there may 
be convulsions at the outset. 

Pharyngeal Diphtheria. — In a typical case there is at first redness of 
the fauces, and the child complains of slight difficulty in swallowing. 
The membrane first appears upon the tonsils, and it may be a little diffi- 
cult to distinguish a patchy diphtheritic pellicle from the exudate of the 
tonsillar crypts. The pharyngeal mucous membrane is reddened, and the 
tonsils themselves are swollen. By the third day the membrane has covered 
the tonsils, the pillars of the fauces, and perhaps the uvula, which is thick- 
ened and cedematous, and may fill completely the space between the swollen 
tonsils. The membrane may extend to the posterior wall of the pharynx. 
At first grayish-white in color, it changes to a dirty gray, often to a yellow- 
white. It is firmly adherent, and when removed leaves a bleeding, slightly 
eroded surface, which is soon covered by fresh exudate. The glands in 
the neck are swollen, and may be tender. The general condition of a 
patient in a ease of moderate severity is usually good; the temperature not 
very high, in the absence of complications ranging from 102° to 103°. 
The pulse range is from 100 to 120. The local condition of the throat 
is not of great severity, and the constitutional depression is slight. The 
symptoms gradually abate, the swelling of the neck diminishes, the mem- 
branes separate, and from the seventh to the tenth day the throat becomes 
clear and convalescence sets in. 

Clinically atypical forms are extremely common, and I follow here 
Koplik's division: 

(a) There may be no local manifestation of membrane, but a simple 
catarrhal angina associated sometimes with a croupy cough. The detec- 
tion in these cases of the Klebs-Loeffler bacillus can alone determine the 
diagnosis. Such cases are of great moment, inasmuch as they may com- 
municate the severer disease to other children. 

(b) There are cases in which the tonsils are covered by a pultaceous 
exudate, not a consistent membrane. 

(c) Cases presenting a punctate form of membrane, isolated, and usually 
on the surface of the tonsils. 

(d) Cases which begin and often run their entire course with the local 
picture of a typical lacunar amygdalitis. They may be mild, and the local 
exudate may not extend, but in other cases there are rapid development 
of membrane, and extension of the disease to the pharynx and the nose, 
with severe septic and constitutional symptoms. 



DIPHTHERIA. 



14? 



(e) Under the term " latent diphtheria " Heubner has described cases, 
usually secondary, occurring chiefly in hospital practice, in young persons 
the subject of wasting affections, such as rickets and tuberculosis. There 
are fever, naso-pharyngeal catarrh, and gastro-intestinal disturbances. 
Diphtheria may not be suspected until severe laryngeal complications de- 
velop, or the condition may not be determined until autopsy. 

Systemic Infection. — The constitutional disturbance in mild diphtheria 
is very slight. There are instances, too, of extensive local disease without 
grave systemic symptoms. As a rule, the general features of a case bear 
a definite relation to the severity of the local disease. There are rare in- 
stances in which from the outset the constitutional prostration is extreme, 
the pulse frequent and small, the fever high, and the nervous phenomena 
are pronounced; the patient may sink in two or three days overwhelmed by 
the intensity of the toxaemia. There are cases of this sort in which the 
exudate in the throat may be slight, but usually the nasal symptoms are 
pronounced. The temperature may be very slightly raised or even sub- 
normal. More commonly the severe systemic symptoms appear at a later 
date when the pharyngeal lesion is at its height. They are constantly pres- 
ent in extensive disease, and when there is a sloughing, foetid condition. 
The lymphatic glands become greatly enlarged; the pallor is extreme; the 
face has an ashen-gray hue; the pulse is rapid and feeble, and the tempera- 
ture sinks below normal. In the most aggravated forms there are gan- 
grenous processes in the throat, and in rare instances, when life is pro- 
longed, extensive sloughing of the tissues of the neck. 

Escherich accounts for the discrepancy sometimes observed between 
the severity of the constitutional disturbance and the intensity of the local 
process, by assuming varying degrees of susceptibility to the diphtheria 
bacillus on the one hand, and to its poison on the other hand. With high 
local susceptibility of a part to the action of the bacillus, with little gen- 
eral susceptibility to the toxine, there is extensive local exudate with mild 
constitutional symptoms, or vice versa, severe systemic disturbance with 
limited local inflammation. 

A leucocytosis is present in diphtheria. Morse does not think it of any 
prognostic value, since it is present and may be pronounced in mild cases. 

Nasal Diphtheria. — In cases of pharyngeal diphtheria the Klebs-Loef- 
fler bacillus is found on the mucous membrane of the nose and in the secre- 
tions, even when no membrane is present, but it may apparently produce 
two affections similar enough locally but widely differing in their general 
features. 

In membranous or fibrinous rhinitis, a very remarkable affection seen 
usually in children, the nares are occupied by thick membranes, but there 
is an entire absence of any constitutional disturbance. The condition 
has been studied very carefully by Park, Abbott, Gerber and Podack, and 
others. Pavenel has collected 77 cases (Medical News, 1895, I), in 41 of 
which a bacteriological examination w as made, in 33 the Klebs-Loefller ba- 
cillus being present. All the cases ran a benign course, and in all but a 
few the membrane was limited to the nose, and the constitutional symp- 
toms were either absent or very slight. Remarkable and puzzling features 



148 



SPECIFIC INFECTIOUS DISEASES. 



are that the disease runs a benign course, and that infection of other chil- 
dren in the family is extremely rare. 

On the other hand, nasal diphtheria is apt to present a most malignant 
type of the disease. The infection may be primary in the nose, and in a 
case recently in my wards there was otitis media, and the Klebs-Loeffler 
bacillus was separated from the discharge before the condition of nasal 
diphtheria was suspected. While some cases are of mild character, others 
are Very intense, and the constitutional symptoms most profound. The 
glandular inflammation is usually very intense, owing, as J acobi points out, 
to the great richness of the nasal mucosa in lymphatics. From the nose 
the inflammation may extend through the tear-ducts to the conjunctivae 
and into the antra. 

Laryngeal Diphtheria. — Membranous Croup. — "With a very large pro- 
portion of all the cases of membranous laryngitis the Klebs-Loeffler bacil- 
lus is associated; in a much smaller number other organisms, particularly 
the streptococcus, are found. Membranous croup, then, may be said to be 
either genuine diphtheria or diphtheroid in character. Of 286 cases in 
which the disease was confined to the larynx or bronchi, in 229 the Klebs- 
Loeffler bacilli were found. In 57 they were not present, but 17 of these 
cultures were unsatisfactory (Park and Beebe). The streptococcus cases 
are more likely to be secondary to other acute diseases. 

Symptoms. — Naturally, the clinical symptoms are almost identical in 
the non-specific and specific forms of membranous laryngitis. 

The affection begins like an acute laryngitis with slight hoarseness and 
rough cough, to which the term croupy has been applied. After these 
symptoms have lasted for a day or two with varying intensity, the child 
suddenly becomes worse, usually at night, and there are signs of impeded 
respiration. At first the difficulty in breathing is paroxysmal, clue prob- 
ably to more or less spasm of the muscles of the glottis. Soon the dyspnoea 
becomes continuous, inspiration and expiration become difficult, particu- 
larly the latter, and with the inspiratory movements the epigastrium and 
lower intercostal spaces are retracted. The voice is husky and may be re- 
duced to a whisper. The color gradually changes and the imperfect aera- 
tion of the blood is shown in the lividity of the lips and finger-tips. Eest- 
lessness comes on and the child tosses from side to side, vainly trying to 
get breath. Occasionally, in a severer paroxysm, portions of membrane are 
coughed out. The fever in membranous laryngitis is rarely very high and 
the condition of the child is usually very good at the time of the onset. 
The pulse is always increased in frequency and if cyanosis be present is 
small. In favorable cases the dyspnoea is not very urgent, the color of the 
face remains good, and after one or two paroxysms the child goes to sleep 
and wakes in the morning, perhaps without fever and feeling comfortable. 
The attack may recur the following night with greater severity. In un- 
favorable cases the dyspnoea becomes more and more urgent, the cyanosis 
deepens, the child, after a period of intense restlessness, sinks into a semi- 
comatose state, and death finally occurs from poisoning of the nerve cen- 
tres by carbon dioxide. In other cases the onset is less sudden and is pre- 
ceded by a longer period of indisposition. As a rule, there are pharyngeal 



DIPHTHERIA. 



149 



symptoms. The constitutional disturbance may be more severe, the fever 
higher, and there may be swelling of the glands of the neck. Inspection 
of the fauces may show the presence of false membranes on the pillars or 
on the tonsils. Bacteriological examination can alone determine whether 
these are due to the Klebs-Loeffler bacillus or to the streptococcus. Fagge 
held that non-contagious membranous croup may spread upward from the 
larynx just as diphtheritic inflammation is in the habit of spreading down- 
ward from the fauces. Ware, of Boston, whose essay on croup is perhaps 
the most solid contribution to the subject made in this country, reported 
the presence of exudate in the fauces in 74 out of 75 cases of croup. These 
observations were made prior to 1840, during periods in which diphtheria 
was not epidemic to any extent in Boston. In protracted cases pulmonary 
symptoms may develop, which are sometimes due to the difficulty in expel- 
ling the muco-pus from the tubes; in others, the false membrane extends 
into the trachea and even into the bronchial tubes. During the paroxysm 
the vesicular murmur is scarcely audible, but the laryngeal stridor may be 
loudly communicated along the bronchial tubes. 

Diphtheria of Other Parts. — Primary diphtheria occurs occasionally 
in the conjunctiva. It follows in some instances the affection of the nasal 
mucous membrane. Some of the cases are severe and serious, but it has 
been shown by C. Frankel and others that the diphtheria bacilli may be 
present in a conjunctivitis catarrhal in character, or associated with only 
slight croupous deposits. 

Diphtheria of the external auditory meatus is seen in rare instances in 
which there are diphtheritic otitis media and extension through the tym- 
panic membrane. 

Diphtheria of the skin is most frequently seen in the severer forms of 
pharyngeal diphtheria, in which the membrane extends to the mouth and 
lips, and invades the adjacent portions of the skin of the face. The skin 
about the anus and genitals may also be attacked. Pseudo-membranous 
inflammation is not uncommon on ulcerated surfaces and wounds. In 
very many of these cases it is a streptococcus infection, but in a majority, 
perhaps, in which the patient is suffering with diphtheria, the Klebs-Loef- 
fler bacillus will be found in the fibrinous exudate. As proposed by Welch, 
the term " wound diphtheria " should be limited to infection of a wound 
by the Klebs-Loeffler bacillus. This " may manifest itself as a simple 
inflammation, or inflammation with superficial necrosis, or inflammation 
with more or less adherent pseudo-membrane. The conditions as regards 
varying intensity and character of the infection, association with other 
bacteria, particularly streptococci, and the necessity of a bacteriological 
examination to establish the diagnosis, are in no way different in the diph- 
theria of wounds from those in diphtheria of mucous membranes. Wound 
diphtheria may oecnr without demonstrable connection with cases of diph- 
theria and without affection of the throat in the individual attacked, but 
such occurrences are rare" (Welch). Paralysis may follow wound diph- 
theria, rseudo-membranous inflammations of wounds are caused more fre- 
quently by other micro-organisms, particularly the streptococcus pyogenes, 
than by the Klebs-Loeffler bacillus. The fibrinous membrane so common 



150 



SPECIFIC INFECTIOUS DISEASES. 



in the neighborhood of the tracheotomy wound in diphtheria is rarely 
associated with the Klebs-Loeffler bacillus. Diphtheria of the genitals is 
occasionally seen. 

Complications and Sequelae. — Of local complications, haemor- 
rhage from the nose or throat may occur in the severe ulcerative cases. 
Skin rashes are not infrequent, particularly the diffuse erythema. Occa- 
sionally there is urticaria and in the severe cases purpura. Fatal cases 
almost invariably show capillary bronchitis with broncho-pneumonia and 
large patches of collapse, or the septic particles may reach the bronchi and 
excite gangrenous processes which may lead to severe and fatal haemor- 
rhage. Jaundice, usually a feature of the toxaemia, may be catarrhal, and 
not of serious import. 

Eenal complications are common. Albuminuria is present in all severe 
cases. It is only when the albumin is in considerable quantity and asso- 
ciated with epithelial or blood casts that the condition indicates parenchym- 
atous nephritis and is alarming. The nephritis may appear quite early in 
the disease. It sets in occasionally with complete suppression of the urine. 
In comparison with scarlet fever the renal changes lead less frequently to 
general dropsy. In rare instances there may be coma, and even convulsions, 
without albumin in the urine, and without dropsy. Mention has already 
been made of the frequency and gravity of septicaemia and local infec- 
tion of internal parts due to invasion of the streptococcus pyogenes, 
which is a very constant attendant of the Klebs-Loeffler bacillus in the 
human body. 

Of the sequelae of diphtheria, paralysis is by far the most important. 
This can be experimentally produced in animals by the inoculation of the 
toxins. The paralysis occurs in a variable proportion of the cases, ranging 
from 10 to 15 and even to 20 per cent. It is strictly a sequel of the dis- 
ease, coming on usually in the second or third week of convalescence. 
Occasionally it occurs as early as the seventh or eighth day of the disease. 
It may follow very mild cases; indeed, the local lesion may be so trifling 
that the onset of the paralysis alone calls attention to the true nature of 
the trouble. It is proportionately less frequent in children than in adults. 

The disease is a toxic neuritis, due to the absorption of the poison. 
In 494 cases collected by Woodhead, the palate was involved in 155, the 
ocular muscles in 197, in 10 other muscles. Mnety-one of the patients 
died. 

Of the local paralyses the most common is that which affects the pal- 
ate. This gives a nasal character to the voice, and, owing to a return of 
liquids through the nose, causes a difficulty in swallowing. These may be 
the only symptoms. The palate is seen to be relaxed and motionless, and 
the sensation in it is also much impaired. The affection may extend to 
the constrictors of the pharynx, and deglutition become embarrassed. 
Within two or three weeks or even a shorter time the paralysis disappears. 
In many cases the affection of the palate is only part of a general neuritis. 
Of other local forms perhaps the most common are paralysis of the eye- 
muscles, intrinsic and extrinsic. There may be strabismus, ptosis, and loss 
of power of accommodation. Facial paralysis may develop, and in one 



DIPHTHERIA. 



151 



case, two and a half years later, it still persisted with contractures. The 
neuritis may be confined to the nerves of one limb, though more commonly 
the legs or the arms are affected together. Very often with the palatal pa- 
ralysis is associated a weakness of the legs without definite palsy but with 
loss of the knee-jerk. 

The multiple form of diphtheritic neuritis is not uncommon. It may 
begin with the palatal affection, or with loss of power of accommodation 
and loss of the tendon reflexes. This last is an important sign, which, as 
Bernhardt, Buzzard, and E. L. MacDonnell have shown, may occur early, 
but is not necessarily followed by other symptoms of neuritis. There is 
paraplegia, which may be complete or involve only the extensors of the 
feet. The paralysis may extend and involve the arms and face and render 
the patient entirely helpless. The muscles of respiration may be spared. 
The chief danger in these severer forms comes from the involvement of 
the heart and of the muscles of respiration; but the outlook is in many 
cases not so bad as the patient's condition would indicate. Of 13 cases col- 
lected by Cadet de Gassicourt 6 died. The sphincters may be involved, 
though they are often spared. 

Heart. — According to the studies of J. J. Thomas and Hibbard (Bos- 
ton City Hospital), about one death in five in diphtheria is due to heart 
failure. It is most frequent during the second week of the disease. A 
slow pulse is a more common indication of a serious condition than a 
rapid one. Perhaps after an exaggeration of symptoms the child presents 
an unusual pallor; the pulse may become weak and rapid, but more often 
falls to fifty, forty, or even lower. The extremities are cold, the tempera- 
ture' sinks, and death takes place, with all the features of collapse, within a 
few hours. More frequently the fatal collapse comes during convalescence, 
even as late as the sixth or seventh week after apparent recovery. The 
attack may set in abruptly, perhaps following a sudden exertion. More 
commonly there have been symptoms pointing to disturbed cardiac rhythm, 
or even fainting-spells. In some instances vomiting has preceded the 
serious cardiac attack. There may be no physical signs other than slight 
increase in the cardiac dulness and a gallop-rhythm or embryocardia indi- 
cating dilatation. These symptoms were formerly ascribed to cardiac 
thrombosis or to endocarditis. Possibly in some of the cases the result is 
due, as pointed out by Mosler and Lcyden, to an infectious myocarditis, but 
in a majority of the cases the symptoms are probably clue to a neuritis of 
the cardiac nerves. 

Diagnosis. — The presence of the Klebs-LoofhYr bacillus is regarded 
by bacteriologists as the sole criterion of true diphtheria, and as this organ- 
ism may be associated with all grades of throat affections, from a simple 
catarrh to a sloughing, gangrenous process, it is evident that in many 
instances there will he a striking discrepancy between the clinical and the 
bacteriological diagnosis. One inestimable value of the recent studies has 
been the determination of (he diphtheritic character of many of the milder 
forms of tonsillitis and pharyngitis. 

The bacteriological diagnosis is simple. The plan adopted by the 
New York Health Department is a model which may be followed with 



152 



SPECIFIC INFECTIOUS DISEASES. 



advantage in other cities. Outfits for making cultures, consisting of a 
box containing a tube of blood-serum and a sterilized swab in a test-tube, 
are distributed to about forty stations at convenient points in the city. 
A list of these places is published, and a physician can obtain the outfit 
free of cost. The directions are as follows: " The patient should be placed 
in a good light, and, if a child, properly held. In cases where it is possible 
to get a good view of the throat, depress the tongue and rub the cotton 
swab gently but freely against any visible exudate. In other cases, includ- 
ing those in which the exudate is confined to the larynx, avoiding the 
tongue, pass the swab far back and rub it freely against the mucous mem- 
brane of the pharynx and tonsils. Without laying the swab down, with- 
draw the cotton plug from the culture-tube, insert the swab, and rub that 
portion of it which has touched the exudate gently but thoroughly all over 
the surface of the blood-serum. Do not push the swab into the blood- 
serum, nor break the surface in any way. Then replace the swab in its own 
tube, plug both tubes, put them in the box, and return the culture outfit 
at once to the station from which it was obtained."- The culture-tubes 
which have been inoculated are kept in an incubator at 37° C. for twelve 
hours and are then ready for examination. Some prefer a method by which 
the material from the throat collected on a sterile swab, or, as recom- 
mended by von Esmarch, on small pieces of sterilized sponge, is sent to 
the laboratory where the cultures and microscopical examination are made 
by a bacteriologist. 

An immediate diagnosis without the use of cultures is often possible 
by making a smear preparation of the exudate from the throat. The Klebs- 
Loeffier bacilli may be present in sufficient numbers, and may be quite 
characteristic to an expert. In this connection may be given the following 
statement by Park, who has had such an exceptional experience: " The ex- 
amination by a competent bacteriologist of the bacterial growth in a blood- 
serum tube which has been properly inoculated and kept for fourteen hours 
at the body temperature can be thoroughly relied upon in cases where there 
is visible membrane in the throat, if the culture is made during the period 
in which the membrane is forming, and no antiseptic, especially no mer- 
curial solution, has lately been applied. In cases in which the disease is 
confined to the larynx or bronchi, surprisingly accurate results can be 
obtained from cultures, but in a certain proportion of cases no diphtheria 
bacilli will be found in the first culture, and yet will be abundantly present 
in later cultures. We believe, therefore, that absolute reliance for a diag- 
nosis cannot be placed upon a single culture from the pharynx in purely 
laryngeal cases." 

Where a bacteriological examination cannot he made, tlie practitioner must 
regard as suspicious all forms of throat affections in children, and carry out 
measures of isolation and disinfection. In this way alone can serious errors 
be avoided. It is not, of course, in the severer forms of membranous an- 
gina that mistake is likely to occur, but in the various lighter forms, many 
of which are in reality due to the Klebs-Loeffler bacillus. 

A large proportion of the cases of diphtheroid inflammation of the 
throat are due to the streptococcus pyogenes. They are usually milder, 



DIPHTHERIA. 



153 



and the liability to general infection is less intense; still, in scarlet fever 
and other specific fevers some of the most virulent cases of throat disease 
which we see, with intense systemic infection, are caused by this micro- 
organism. These streptococcus cases are probably much less numerous 
than the figures which I have given would indicate. The more careful ex- 
aminations in the diphtheria pavilions of hospitals, particularly in Eu- 
rope, have shown that in the large majority of cases admitted the Klebs- 
Loefner bacillus is present. I have already referred, under the section on 
scarlet fever, to the question of the diagnosis between scarlet fever with 
severe angina and diphtheria. 

Prognosis. — In hospital practice the mortality was formerly from 
30 to 50 per cent. In the Boston City Hospital with the antitoxin 
treatment the death-rate has fallen from 46 to 12 per cent. In country 
places the disease may display an appalling virulence. In cases of ordi- 
nary severity the outlook is usually good. Death results from involvement 
of the larynx, septic infection, sudden heart-failure, diphtheritic paralysis, 
occasionally from uraemia, and sometimes from broncho-pneumonia devel- 
oping during convalescence. 

Prophylaxis. — Isolation of the sick, disinfection of the clothing 
and of everything that has come in contact with the patient, careful 
scrutiny of the milder cases of throat disorder, and more stringent surveil- 
lance in the period of convalescence are the essential measures to prevent 
the spread of the disease. Suspected cases in families or schools should be 
at once isolated or removed to a hospital for infectious disorders. When a 
death has occurred from diphtheria, the body should be wrapped in a sheet 
which has been soaked in a corrosive-sublimate solution (1 to 3,000), and 
placed in a closely sealed coffin. The funeral should always be private. 

In cases of well-marked diphtheria these precautions are usually car- 
ried out, but the chief danger is from the milder cases, particularly the 
ambulatory form, in which the disease has perhaps not been suspected. 
But from such patients mingling with susceptible children the disease is 
often conveyed. The healthy children in a family in which diphtheria 
exists may carry the disease to their school-fellows. The question of the 
influence of isolation hospitals on the spread of the disease has, I think, 
been solved in Boston, a city which has suffered terribly from diphtheria. 
The ratio of mortality per 10,000 living in 1893 was 11+, and in 1891 it 
was 19— (-. In 1895 the infectious pavilion was opened. Prior to that year 
only about 10 per cent of the reported cases were treated in hospital; in 
succeeding years 50 per cent were treated in hospital. In 1898 the mor- 
tality per 10,000 had fallen to 3, and in 1899 it was 4.9. 

A very important matter in the prophylaxis relates to the period of 
convalescence. It lias been shown by numerous observations that, after all 
the membrane lias cleared away, virulent bacilli may persist in the throat 
from periods ranging from six weeks to six months, or even longer. There 
is evidence to show thai the disease may be communicated by such patients, 
so that isolation should be continued in any given case until the bacteri- 
ological examination shows that the throat is free. 

It can not be too strongly emphasized that the important elements in 



154: 



SPECIFIC INFECTIOUS DISEASES. 



the prophylaxis of diphtheria are the rigid scrutiny of the milder types of 
throat affection, and the thorough isolation and disinfection of the indi- 
vidual patients. 

Careful attention should be given to the throats and mouths of chil- 
dren, particularly to the teeth and tonsils, as Caille has urged. Swollen 
and enlarged tonsils should be removed. In persons exposed, the anti- 
septic mouth washes, such as corrosive sublimate (1 to 10,000), chlorine 
water (1 to 1,100), or swabbing the throat with a diluted Loeffler's solu- 
tion, should be employed. 

Treatment. — The important points are hygienic measures to pre- 
vent the spread of the malady, local treatment of the throat to destroy 
the bacilli, medication, general or specific, to counteract the effects of the 
toxines, and, lastly, to meet the complications and sequelae. 

(a) Hygienic Measures. — The patient should be in a room from which 
the carpets, curtains, and superfluous furniture have been removed. The 
temperature should be about 68°, and thorough ventilation should be 
secured. The air may be kept moist by a kettle or a steam-atomizer. If 
possible, only the nurse, the child's mother, and the doctor should come 
in contact with the patient. During the visit the physician should wear 
a linen overall, and on leaving the room he should thoroughly wash his 
hands and face in a corrosive-sublimate solution. The strictest quarantine 
should be employed against other members in the house. 

(#) Local Treatment. — In mild cases the throat symptoms are alone 
prominent. Vigorous local treatment from the outset should be carried 
out, taking especial care in all instances to avoid mechanical injury to 
the tissues. A very large number of solutions have been recommended. 
They are best employed with a swab of cotton-wool or a soft sponge, or 
irrigation with hot antiseptic solutions may be used. The direct applica- 
tion with a swab of cotton-wool or sponge is, as a rule, effective. In many 
young children it is really a most trying procedure to carry out the treat- 
ment, and sometimes one is compelled to desist. The nurse should hold 
the child on her knees, well wrapped in a shawl, with its head resting on 
her shoulder. The nose is then held, and so soon as the child opens its 
mouth a cork should be placed between the molar teeth. The local appli- 
cation can then be made, or thorough irrigation carried out. In infants 
the disinfecting fluids are sometimes better applied through the nostrils. 
The following solutions may be employed: 

Loefner's solution: Menthol, 10 grammes dissolved in toluol to 36 cc. 
Liq. Ferri sesquichlorati, 4 cc; alcohol absol., 60 cc. 

Corrosive sublimate, 1 to 1,000, either alone or with tartaric acid, 5 
grammes to the litre. 

Carbolic acid, 3 per cent in 30 per cent alcohol solution, is much em- 
ployed; some prefer to touch the small spots of exudate with pure carbolic 
acid. 

Another solution is: The tincture of the perchloride of iron, a drachm 
and a half, in glycerine, one ounce, water, one ounce, with from 15 to 20 
minims of carbolic acid. Chlorine water, boric acid, peroxide of hydrogen, 
iodoform, lactic acid, trypsin, and papain are also recommended. 



DIPHTHERIA. 



155 



Loeffler's solution, which has been given a very thorough trial, is per- 
haps the most satisfactory. 

Nasal diphtheria requires prompt and thorough disinfection of the 
passages. Jacobi recommends chloride of sodium, saturated boric acid, 
or 1 part of bichloride of mercury, 35 of chloride of sodium, and 1,000 
of water, or the 1-per-cent solution of carbolic acid. Loeffler's solution 
may be diluted and applied with a syringe or a spray. To be effectual 
the injection must be properly given. The nurse should be instructed to 
pass the nozzle of the syringe horizontally, not vertically; otherwise the 
fluid will return through the same nostril. 

When the larynx becomes involved, a steam tent may be arranged 
upon the bed, so that the child may breathe an atmosphere saturated 
with moisture. If the dyspnoea becomes urgent, an emetic of sulphate of 
zinc or ipecacuanha may be given. When the signs of obstruction are 
marked there should be no delay in the performance of intubation or 
tracheotomy. 

Hot applications to the neck are usually very grateful, particularly to 
young children, though in the case of older children and adults the ice 
poultices are to be preferred. 

(c) General Measures. — The food should be liquid — milk, beef juices, 
barley water, albumen water, and soups. The child should be encouraged 
to drink water freely. When the pharyngeal involvement is very great 
and swallowing painful, nutritive enemata should be used. In cases with 
severe constitutional symptoms stimulants should be given early. 

Medicines given internally are of very little avail in the disease. There 
is still a widespread belief in the profession that forms of mercury are bene- 
ficial. The tincture of the perchloride of iron is also very warmly recom- 
mended. We are still, however, without drugs which can directly coun- 
teract the tox-albumins of this disease, and we must rely on general 
measures of feeding and stimulants to support the strength. 

The convalescence of the disease is not without its dangers, and patients 
should be very carefully watched, particularly if there are signs of heart 
weakness. 

The diphtheritic paralysis requires rest in bed, and in those cases in 
which the heart rhythm is disturbed the avoidance of sudden exertion. 
In the chronic forms with wasting, massage, electricity, and strychnine 
are invaluable aids. If swallowing becomes very difficult, the patient must 
be fed with the stomach-tube, which is very much preferable to feeding 
per rectum. 

(d) Antitoxin Treatment. — As the years go on additional experi- 
ence has shown that, thoroughly carried out, this method of treatment is 
both safe and efficacious. There are no reasonable grounds for skepticism 
on the part of intelligent practitioners, and still less on the part of those 
in charge of the hospitals for infectious diseases. In this country, those in 
charge of institutions who still have any lingering doubts should, in the 
interests of their little patients, and in a spirit of humility, visit the South 
Department of the Boston City Hospital, and learn a few salutary lessons 
from its director, Dr. McCollum. 

10 



156 



SPECIFIC INFECTIOUS DISEASES. 



The principle of action depends on the circumstance that the blood- 
sernm of an animal rendered immune, when introduced into another ani- 
mal, protects it from infection with the diphtheria bacilli, and has also an 
important curative influence upon diphtheria, whether artificially given to 
animals, or spontaneously acquired by man. In the preparation of the 
blood-serum a uniform standard strength is procured. The antitoxin unit 
is the amount of antitoxin which, injected into a guinea-pig of 250 grammes 
in weight, neutralizes 100 times the minimum fatal dose of toxin of stand- 
ard strength. 

Dosage. — This is one of the most important questions relating to the 
use of the antitoxin. J. H. McCollum, of the Boston City Hospital, who 
has probably had a richer experience with the disease than any man in this 
country, insists that the guiding practice in the use of the antitoxin is to 
give it until the characteristic effects are produced, whether 1,000 or 70,000 
units be required for this result. He very rightly remarks that in the case 
of a patient ill with diphtheria there is no way of estimating the quantity 
of toxin generated by the membrane, and therefore one must administer the 
agent until the characteristic effect is produced — viz., the shriveling of the 
membrane, the diminution of the nasal discharge, the correction of the 
fetid odor, and a general improvement in the condition of the patient. No 
case, he says, in the acute stage should be considered hopeless. " When 
one sees a patient with membrane covering the tonsils and uvula, profuse 
sanious discharge from the nose, spots of ecchymosis on the body and ex- 
tremities, cold, clammy hands and feet, a feeble pulse, and the nauseous 
odor of diphtheria, and finds that after the administration of 10,000 units of 
antitoxin in two doses the condition of the patient improves slightly; that 
after 10,000 units more have been given there is a marked abatement in the 
severity of the symptoms; that when an additional 10,000 units have been 
given the patient is apparently out of danger, and eventually recovers — one 
must believe in the curative power of antitoxin. When one sees a patient 
in whom the intubation tube has been repeatedly clogged, when the hope- 
less condition of the patient changes for the better after the administra- 
tion of 50,000 units, one can not help but be convinced of the importance 
of giving large doses of antitoxin in the very severe and apparently hope- 
less cases. In the majority of instances these large doses are not required, 
particularly if the patients are seen early in the attack, 4,000 to 6,000 
units being enough to produce the characteristic effect on the membrane." 

Favorable effects are seen in improvement in both the local and general 
condition. The swelling of the fauces subsides, the membrane begins to 
disappear, the temperature falls, and the pulse becomes slower. 

Untoward Effects. — Of these the most common are urticaria and arthral- 
gia, but they are trifling and unimportant. Abscess is rare. 

Results. — Of 183,256 cases treated in 150 cities previous to the serum 
period, the mortality was 38.4 per cent. Since the introduction of serum 
132,548 cases have been treated, with a mortality of 14.6 per cent. Leav- 
ing out those not treated with the serum, the mortality was 9.8 per cent 
(Edwin Rosenthal). In the Boston City Hospital prior to 1895 the death- 
rate from diphtheria was 46 per cent; in five subsequent years, with the 



ERYSIPELAS. 



157 



treatment of between seven and eight thousand oases, the mortality has 
been just 12 per cent. One of the most remarkable and interesting records 
is from the city of Chicago. In the ten years before the antitoxin treat- 
ment, from 1886 to 1895, there was a yearly average death-rate from diph- 
theria and croup of 1,417, while in three years after the antitoxin treat- 
ment was begun the yearly average was only 851. 

Immunization for the Prevention of Diphtheria. — Persons exposed to 
diphtheria may be protected by a sufficient dose of the antitoxin. Chil- 
dren, particularly, should receive an immunizing injection at once. The 
minimum dose recommended by the New York Board of Health is 300 
units for a child, 500 for an adult, which may be repeated in a few days. 

XVII. ERYSIPELAS. 

Definition. — An acute, contagious disease, characterized by a special 
inflammation of the skin caused by streptococcus erysipelatos seu pyo- 
genes. 

Etiology. — Erysipelas is a widespread affection, endemic in most com- 
munities, and at certain seasons epidemic. We are as yet ignorant of the 
atmospheric or telluric influences which favor the diffusion of the poison. 

It is particularly prevalent in the spring of the year. Of 2,012 cases 
collected by Anders, 1,214 occurred during the first five months of the 
year. April had the largest number of cases. The affection prevails ex- 
tensively in old, ill-ventilated hospitals and institutions in which the sani- 
tary conditions are defective. With the improved sanitation of late years 
the number of cases has materially diminished. It has been observed, 
however, to break out in new institutions under the most favorable hygienic 
circumstances. Erysipelas is both contagious and inoculable; but, except 
under special conditions, the poison is not very virulent and does not 
seem to act at any great distance. It can be conveyed by a third person. 
The poison certainly attaches itself to the furniture, bedding, and walls 
of rooms in which patients have been confined. 

The disposition to the disease is widespread, but the susceptibility is 
specially marked in the case of individuals with wounds or abrasions of 
any sort. Recently delivered women and persons who have been the sub- 
jects of surgical operations are particularly prone to it. A wound, how- 
ever, is not necessary, and in the so-called idiopathic form, although it may 
be difficult to say that there was not a slight abrasion about the nose or 
lips, in very many cases there certainly is no observable external lesion. 

Chronic alcoholism, debility, and Bright' s disease are predisposing 
agents. Certain persons show a special susceptibility to erysipelas, and 
it may recur in them repeatedly. There are instances, too, of a family 
predisposition. 

The specific agent of the disease is a streptococcus growing in long 
chains, which is included under the group name Streptococcus pyogenes, 
with which Streptococcus erysipelatos appears to be identical. The fever 
and constitutional symptoms are due in great part to the toxins; the more 



158 



SPECIFIC INFECTIOUS DISEASES. 



serious visceral complications are the result of secondary metastatic in- 
fection. 

Immunity. — Susceptible animals can be rendered immune to virulent 
streptococci by repeated non-lethal injections of cultures. Marmorek's 
protective serum, prepared by inoculating the horse and other animals 
with cultures of intensified virulence, belongs to the bactericidal and not 
to the antitoxic sera. Notwithstanding some apparently favorable results, 
its value in the treatment of human infections has not been demonstrated. 

Morbid Anatomy. — Erysipelas is a simple inflammation. In its 
uncomplicated forms there is seen, post mortem, little else than inflamma- 
tory oedema. Investigations have shown that the cocci are found chiefly 
in the lymph-spaces and most abundantly in the zone of spreading inflam- 
mation. In the uninvolved tissue beyond the inflamed margin they are 
to be found in the lymph-vessels, and it is here, according to Metschni- 
koff and others, that an active warfare goes on between the leucocytes 
and the cocci (phagocytosis). In more extensive and virulent forms of 
the disease there is usually suppuration. It is stated that the inflamma- 
tion may pass inward from the scalp through the skull to the meninges. 
This I have never seen, but in one case I traced the extension from the 
face along the fifth nerve to the meninges, where an acute meningitis and 
thrombosis of the lateral sinus were excited. 

The visceral complications of erysipelas are numerous and important. 
The majority of them are of a septic nature. Infarcts occur in the lungs, 
spleen, and kidneys, and there may be the general evidences of pysemic 
infection. 

Some of the worst cases of malignant endocarditis are secondary to 
erysipelas; thus, of 23 cases, 3 occurred in connection with this disease. 
Septic pericarditis and pleuritis also occur. 

As just mentioned, the disease may in rare cases extend to and involve 
the meninges. Pneumonia is not a very common complication. 

Acute nephritis is also met with; it is often ingrafted upon an old 
chronic trouble. 

Symptoms. — The following description applies specially to erysipelas 
of the face and head, the form of the disease which the physician is most 
commonly called upon to treat. 

The incubation is variable, probably from three to seven days. 

The stage of invasion is often marked by a rigor, and followed by a 
rapid rise in the temperature and other characteristics of an acute fever. 
When there is a local abrasion,- the spot is slightly reddened; but if the 
disease is idiopathic, there is seen within a few hours slight redness over 
the bridge of the nose and on the cheeks. The swelling and tension of the 
skin increase and within twenty-four hours the external symptoms are weir 1 
marked. The skin is smooth, tense, and cedematous. It looks red, feels 
hot, and the superficial layers of the epidermis may be lifted as small blebs. 
The patient complains of an unpleasant feeling of tension in the skin; 
the swelling rapidly increases; and during the second day the eyes are 
usually closed. The first-affected parts gradually become pale and less 
swollen as the disease extends at the periphery. When it reaches the fore- 



ERYSIPELAS. 



159 



head it progresses as an advancing ridge, perfectly well defined and raised; 
and often, on palpation, hardened extensions can be felt beneath the^skin 
which is not yet reddened. Even in a case of moderate severity, the face 
is enormously swollen, the eyes are closed, the lips greatly cedematous, the 
ears thickened, the scalp is swollen, and the patient's features are quite 
unrecognizable. The formation of blebs is common on the eyelids, ears, 
and forehead. The cervical lymph-glands are swollen, but are usually 
masked in the oedema of the neck. The temperature keeps high without 
marked remissions for four or five days and then defervescence takes place 
by crisis. Leucocytosis is present. Kirkbride has noted the presence in 
one case of leucin and tyrosin in the urine. The general condition of the 
patient varies much with his previous state of health. In old and de- 
bilitated persons, particularly in those addicted to alcohol, the constitu- 
tional depression from the outset may be very great. Delirium is present, 
the tongue becomes dry, the pulse feeble, and there is marked tendency to 
death from toxsemia. In the majority of cases, however, even with ex- 
tensive lesions, the constitutional disturbance, considering the height of 
the fever range, is slight. The mucous membrane of the mouth and throat 
may be swollen and reddened. The erysipelatous inflammation may extend 
to the larynx, but the severe oedema of this part occasionally met with is 
commonly due to the extension of the inflammation from without in- 
ward. 

There are cases in which the inflammation extends from the face to the 
neck, and over the chest, and may gradually migrate or wander over the 
greater part of the body (E. migrans). 

The close relation between the erysipelas coccus and the pus organisms 
is shown by the frequency with which suppuration occurs in facial ery- 
sipelas. Small cutaneous abscesses are common about the cheeks and 
forehead and neck, and beneath the scalp large collections of pus may 
accumulate. Suppuration seems to occur more frequently in some epi- 
demics than in others, and at the Philadelphia Hospital one year nearly 
all the cases in the erysipelas wards presented local abscesses. 

Complications. — Meningitis is rare. The cases in which death 
occurs with marked brain symptoms do not usually show, post mortem, 
meningeal affection. The delirium and coma are due to the fever, or to 
toxaemia. 

Pneumonia is an occasional complication. Ulcerative endocarditis and 
septicaemia are more common. Albuminuria is almost constant, particu- 
larly in persons over fifty. True nephritis is occasionally seen. Da Costa 
has called attention to curious irregular returns of the fever which occur 
during convalescence without any aggravation of the local condition. Ma- 
laria may coexist with erysipelas. L. F. Barker has reported such a case 
occurring in my wards. 

The diagnosis rarely presents any difficulty. Thp mode of onset, the 
rapid rise in fever, and the characters of the local disease are quite dis- 
tinctive. Acute necrosis of bone may sometimes be regarded as erysipelas, 
a mistake which I once saw made in connection with the lower end of the 
femur. 



160 



SPECIFIC INFECTIOUS DISEASES, 



Prognosis.— Healthy adults rarely die. The general mortality in 
hospitals is about 7 per cent, in private practice about 4 per cent (Anders). 
In the new-born, when the disease attacks the navel, it is almost always 
fatal. In drunkards and in the aged erysipelas is a serious affection, and 
death may result either from the intensity of the fever or, more commonly, 
from toxaemia. The wandering or ambulatory erysipelas, which has a more 
protracted course, may cause death from exhaustion. 

Treatment. — Isolation should be strictly carried out, particularly in 
hospitals. A practitioner in attendance upon a case of erysipelas should 
not attend cases of confinement. 

The disease is self -limited and a large majority of the cases get well 
without any internal medication. I can speak definitely on this point, 
having, at the Philadelphia Hospital, treated many cases in this way. 
The diet should be nutritious and light. Stimulants are not required 
except in tliQ old and feeble. For the restlessness, delirium, and insomnia, 
chloral or the bromides may be given; or, if these fail, opium. When the 
fever is high the patient may be bathed or sponged, or, in private practice, 
if there is an objection to this, antipyrin or antifebrin may be given. 

Of internal remedies believed to influence the disease, the tincture of 
the perchloride of iron has been highly recommended. At the Montreal 
General Hospital this was the routine treatment, and doses of half a drachm 
to a drachm were given every three or four hours. I am by no means 
convinced that it has any special action; nor, so far as I know, has any 
medicine, given internally, a definite control over the course of the 
disease. 

Of local treatment, the injection of antiseptic solutions at the margin 
of the spreading areas has been much practised. Two-per-cent solutions 
of carbolic acid, the corrosive sublimate and the biniodide of mercury have 
been much used. The injection should be made not into but just a little 
beyond the border of the inflamed patch. F. P. Henry has treated a large 
number of cases at the Philadelphia Hospital with the last-mentioned drug, 
and this mode of practice is certainly most rational. 

Of local applications, ichthyol is at present much used. The inflamed 
region may be covered with salicylate of starch. Perhaps as good an ap- 
plication as any is cold water, which was highly recommended by Hip- 
pocrates. 

XVIII. SEPTICEMIA AND PYEMIA. 

In these days of asepsis physicians see many more cases of septicemia 
and pyaemia than do the surgeons. For one case in the post-mortem room 
with the anatomical diagnosis of septicemia which comes from the surgical 
or gynaecological departments of the Johns Hopkins Hospital, at least 
fifteen or twenty come from my medical wards. Certain terms must first 
be defined. 

An infection is the morbid process induced by the invasion and growth 
in the body of pathogenic micro-organisms. An infection may be local, 
as in a boil, or general, as in some cases of anthrax. 



SEPTICEMIA AND PYEMIA. 



161 



An intoxication is the morbid condition caused by the absorption of 
toxines, in large part derived from pathogenic organisms. The term 
saprcemia is the equivalent of septic intoxication. 

A hard-and-fast line cannot be drawn between an infection and an 
intoxication, but agents of infection alone are capable of reproduction, 
whereas those of intoxication are chemical poisons, some of which are pro- 
duced by the agency of bacteria, or by vegetable and animal cells. Infec- 
tious diseases which are communicated directly from one person to another 
are termed contagious, and the infecting agent is sometimes spoken of as 
a contagium. " Whether or not an infectious disease is contagious in the 
ordinary sense depends upon the nature of the infectious agent, and espe- 
cially upon the manner of its elimination from and reception by the body. 
Most but not all contagious diseases are infectious. Scabies is a contagious 
disease, but it is not infectious" (Welch). 

There are three chief clinical types of infection. 

1. LOCAL INFECTIONS WITH THE DEVELOPMENT OF TOXINES. 

This is the common mode of invasion of many of the diseases which 
we have already considered. Tetanus, diphtheria, erysipelas, and pneu- 
monia are diseases which have sites of local infection in which the patho- 
genic organisms develop; but the constitutional effects are caused by the 
absorption of the poisonous products. The diphtheria toxine produces all 
the general symptoms, the tetanus toxine every feature, of the disease with- 
out the presence of their respective bacilli. Certain of the symptoms fol- 
lowing the absorption of the toxines are general to all; others are special 
and peculiar, according to the organism which produces them. A chill, 
fever, general malaise, prostration, rapid pulse, restlessness, and headache 
are the most frequent. With but few exceptions the febrile disturbance is 
the most common feature. The most serious effects are seen upon the 
nervous system and upon the heart, and the gravity of the symptoms on 
the part of these organs is to some extent a measure of the intensity of 
the intoxication. The organisms of certain local infections produce poisons 
which have special actions; thus the diphtheria toxine, besides having the 
effects already referred to, is especially prone to attack the nervous system 
and to cause peripheral neuritis. The tetanus toxine has a specific action 
on the motor neurones. 

2. SEPTICEMIA. 1 

Formerly, and in a surgical sense, the term " septicaemia 99 was used to 
designate the invasion of the blood and tissues of the body by the organ- 
isms of suppuration, but in the medical sense the term may be applied 
to any condition in which, with or without a local site of infection, there 
is microbic invasion of the blood and tissues, but without metastatic foci 
of suppuration. Owing to the great development of bacteria in the blood, 
and in order to separate it sharply from local infectious processes with 
toxic invasion of the body, it is proposed to call this condition bacteremia; 
toxaemia denotes the latter state. 



162 



SPECIFIC INFECTIOUS DISEASES. 



(a) Progressive Septicemia from Local Infection. — The common strep- 
tococcus and staphylococcus infection is as a rule first local, and the tox- 
ines alone pass into the blood. In other instances the cocci appear in the 
blood and throughout the tissues, causing a septicaemia which intensifies 
greatly the severity of the case. Other infections in which the bacterial 
invasion, local at first, may become general are pneumonia, typhoid fever, 
anthrax, gonorrhoea, and puerperal fever. 

The clinical features of this form are well seen in the cases of puer- 
peral septicaemia or in dissection wounds, in which the course of the infec- 
tion may be traced along the lymphatics. The symptoms usually set in 
within twenty-four hours, and rarely later than the third or fourth day. 
There is a chill or chilliness, with moderate fever at first, which gradually 
rises and is marked by daily remissions and even intermissions. The pulse 
is small and compressible, and may reach 120 or higher. Gastro-intestinal 
disturbances are common, the tongue is red at the margin, and the dorsum 
is dry and dark. There may be early delirium or marked mental prostra- 
tion and apathy. As the disease progresses there may be pallor of the face 
or a yellowish tint. Capillary haemorrhages are not uncommon. 

The outlook is serious in streptococcus cases. Death may occur within 
twenty-four hours, and in fatal cases life is rarely prolonged for more than 
seven or eight days. On post-mortem examination there may be no gross 
focal lesions in the viscera, and the seat of infection may present only slight 
changes. The spleen is enlarged and soft, the blood may be extremely 
dark in color, and haemorrhages are common, particularly on the serous 
surfaces. Neither thrombi nor emboli are found. 

Many instances of septicaemia are combined infections; thus in diph- 
theria streptococcus septicaemia is a common, and the most serious, event. 
The local disease and the symptoms produced by absorption of the tox- 
ines dominate the clinical picture; but the features are usually much 
aggravated by the systemic invasion. A similar infection may occur in 
typhoid fever and in tuberculosis, and may obscure the typical picture. 
These secondary septicaemias are caused most frequently by the strepto- 
coccus, but may result from the invasion of other bacteria. 

(b) General Septicemia without Recognizable Local Infection. — Cryp- 
togenetic Septicemias. — This is a group of very great interest to the physi- 
cian, the full importance of which we are only now beginning to recognize. 

The subjects when attacked may be in perfect health; more commonly 
they are already weakened by acute or chronic illness. The pathogenic 
organisms are varied. Streptococcus pyogenes is the most common; the 
forms of staphylococcus more rare. Other occasional causal agents are 
micrococcus lanceolatus (pneumococcus), bacillus proteus, and bacillus 
pyocyaneus. Between May 1, 1892, and June 1, 1895, there were exam- 
ined in the post-mortem room from my wards 21 cases of general infec- 
tion, of which 13 were due to streptococcus pyogenes, 2 to staphylococcus 
pyogenes, and 6 to the pneumococcus. In 19 of these cases the patients 
were already the subjects of some other malady, which was aggravated, or 
in most instances terminated, by the general septicaemia. The symptoms 
vary somewhat with the character of the micro-organisms. In the strep- 



SEPTICEMIA AND PYEMIA. 



163 



tococcus cases there may be chills with high, irregular fever, and a more 
characteristic septic state than in the pneumococcus infection. 

Most of these cases come correctly under the term " cryptogenetic septi- 
caemia " as employed by Leube, inasmuch as the local focus of infection is 
not evident during life, and may not be found after death. Although most 
of these cases are terminal infections, yet it is well to bear in mind that 
there are instances of this type of affection coming on in apparently 
healthy persons. The fever may be extremely irregular, characteristic- 
ally septic, and persist for many weeks. Foci of suppuration may not de- 
velop, and may not be found even at autopsy. I have on several occa- 
sions met with cases of an intermittent pyrexia persisting for weeks, in 
which it seemed impossible to give any explanation of the phenomena, and 
some which ultimately recovered, and in which tuberculosis and malaria 
could be almost positively excluded. These cases require to be carefully 
studied bacteriologically. Dreschfeld has described them as idiopathic in- 
termittent fever of pyaemic character. Local symptoms may be absent, 
though in three of his cases there was enlargement of the liver, and in two 
the condition was a diffuse suppurative hepatitis. The pyocyanic disease, 
or cyano-pyaemia, is an extremely interesting form of infection with bacil- 
lus pyocyaneus, of which a large number of cases have been reported of 
late years. (See WollstehYs paper, Archives of Pediatrics, October, 1897, 
and Barker, Jour. Am. Med. Assoc., 1897.) 

3. SEPTICOPYEMIA. 

The pathogenic micro-organisms which invade the blood and tissues 
may settle in certain foci and there cause suppuration. When multiple 
abscesses are thus produced in connection with a general infection, the 
condition is known as pyaemia or, perhaps better, septico-pyaemia. There 
are no specific organisms of suppuration, and the condition of pyaemia may 
be produced by organisms other than the streptococci and staphylococci, 
though these are the most common. Other forms which may invade the 
system and cause foci of suppuration are micrococcus lanceolatus, the gono- 
coccus, bacillus coli communis, bacillus typhi abdominalis, bacillus pro- 
teus, bacillus pyocyaneus, bacillus influenzae, and very probably bacillus 
aerogenes capsulatus. In a large proportion of all cases of pyaemia there 
is a focus of infection, either a suppurating external wound, an osteo- 
myelitis, a gonorrhoea, an otitis media, an empyema, or an area of sup- 
puration in a lymph-gland or about the appendix. In a large majority 
of all these cases the common pus cocci are present. 

In a suppurating wound, for example, the pus organisms induce hyaline 
necrosis in the smaller vessels with the production of thrombi and purulent 
: phlebitis. The entrance of pus organisms in small numbers into the 
blood does not necessarily produce pyaemia. Commonly the transmission 
to various parts from the local focus lakes place by the fragments of 
thrombi which pass as emboli to different parts, where, if the conditions 
are favorable, the pus organisms excite suppuration. A thrombus which 
is not septic or contaminated, when dislodged and impacted in a distant 
vessel, produces at most only a simple infarction; but, coming from an 



164 



SPECIFIC INFECTIOUS DISEASES. 



infected source and containing pns microbes, an independent centre of 
infection is established wherever the embolus may lodge. These inde- 
pendent suppurative centres in pyaemia, known as embolic or metastatic 
abscesses, have the following distribution: 

(a) In external wounds, in osteo-myelitis, and in acute phlegmon of 
the skin, the embolic particles very frequently excite suppuration in the 
lungs, producing the well-known wedge-shaped pyaemic infarcts; from 
these, or rarely by paradoxical embolism or direct passage of bacteria or 
minute emboli through the pulmonary capillaries, metastatic foci of in- 
flammation may occur in other parts. 

(b) Suppurative foci in the territory of the portal system, particularly 
in the intestines, produce metastatic abscesses in the liver with or without 
suppurative pylephlebitis. 

Endocarditis is an event which is very liable to occur in all forms of 
septicaemia, and modifies materially the character of the clinical features. 
Streptococci and staphylococci are the most common organisms present 
in the vegetations, but the pneumococci, gonococci, tubercle bacilli, typhoid 
bacilli, anthrax bacilli, and other forms have been isolated. The vegeta- 
tions which develop at the site of the valve lesion become covered with 
thrombi, particles of which may be dislodged and carried as emboli to 
different parts of the body, causing multiple abscesses or infarcts. 

Symptoms' of Septico-pysemia. — In a case of wound infection, 
prior to the onset of the characteristic symptoms, there may be signs of local 
trouble, and in the case of a discharging wound the pus may change in char- 
acter. The onset of the disease is marked by a severe rigor, during which 
the temperature rises to 103° or 104° and is followed by a profuse sweat. 
These chills are repeated at intervals, either daily or every other day. In 
the intervals there may be slight pyrexia. The constitutional disturbance 
is marked and there are loss of appetite, nausea, and vomiting, and, as 
the disease progresses, rapid emaciation. Transient erythema is not un- 
common. Local symptoms usually occur. If the lungs become involved 
there are dyspnoea and cough. The physical signs may be slight. Involve- 
ment of the pleura and pericardium is common. The tint of the skin is 
changed; at first pale and white, it subsequently becomes bile-tinged. The 
spleen is enlarged, and there may be intense pain in the side, pointing to 
perisplenitis from embolism. Usually in the rapid cases a typhoid state 
supervenes, and the patient dies comatose. 

In the chronic cases the disease may be prolonged for months; the 
chills recur at long intervals, the temperature is irregular, and the condi- 
tion of the patient varies from month to month. The course is usually 
slow and progressively downward. 

Diagnosis. — Pyaemia is a disease frequently overlooked and often 
mistaken for other affections. 

Cases following a wound, an operation, or parturition are readily recog- 
nized. On the other hand, the following conditions may be overlooked: 

Osteo-myelitis. — Here the lesion may be limited, the constitutional 
symptoms severe, and the course of the disease very rapid. The cause of 
the trouble may be discovered only post mortem. 



SEPTICEMIA AND PYEMIA. 



165 



So, too, acute septico-pyaemia may follow gonorrhoea or a prostatic 
abscess. 

Cases are sometimes confounded with typhoid fever, particularly the 
more chronic instances, in which there are diarrhoea, great prostration, 
delirium, and irregular fever. The spleen, too, is often enlarged. The 
marked leucocytosis is an important differential point. 

In some of the instances of ulcerative endocarditis the diagnosis is very 
difficult, particularly in what is known as the typhoid, in contradistinction 
to the septic, type of this disease. In acute miliary tuberculosis the symp- 
toms occasionally resemble those of septicaemia, more commonly those of 
typhoid fever. 

The post-febrile arthritides, such as occur after scarlet fever and gon- 
orrhoea, are really instances of mild septic infection. The joints may 
sometimes suppurate and pyaemia develop. So, also, in tuberculosis of 
the kidneys and calculous pyelitis recurring rigors and sweats due to septic 
infection are common. In this latitude septic and pyaemic processes are 
too often confounded with malaria . In early tuberculosis, or even when 
signs of excavation are present in the lungs, and in cases of suppuration 
in various parts, particularly empyema and abscess of the liver, the diag- 
nosis of malaria is made. The practitioner may take it as a safe rule, 
to which he will find very few exceptions, that an intermittent fever which 
resists quinine is not malaria. 

Other conditions associated with chills which may be mistaken for pyae- 
mia are profound anaemia, certain cases of Hodgkiir's disease, the hepatic 
intermittent fever associated with the lodgment of gall-stones at the orifice 
of the common duct, rare cases of essential fever in nervous women, and 
the intermittent fever sometimes seen in rapidly growing cancer. 

Treatment. — The treatment of septicaemia and pyaemia is largely a 
surgical problem. The cases which come under the notice of the physi- 
cian usually have visceral abscesses or ulcerative endocarditis, conditions 
which are irremediable. We have no remedy which controls the fever. 
Quinine and the new antipyretics may be tried, but they are of little serv- 
ice. Quinine is probably better than antipyrin and.antifebrin, which lower 
the temperature for a time, but when a careful two-hourly twenty-four- 
hour chart is taken, it is often found that the depression under the influ- 
ence of the drug is made up at some other period of the day; a morning 
may be substituted for an afternoon fever. 

The brilliant and remarkable results which follow complete evacuation 
of the pus with thorough drainage give the indication for the only success- 
ful treatment of this condition. 

Unfortunately, in too many cases which the physician is called upon 
to treat, the region of suppuration is not accessible, and" we have to be 
content with the employment of general measures. Antistreptococcus 
scrum has not proved of much value in the treatment of these cases. 

TERMINAL INFECTIONS. 

It may seem paradoxical, but there is truth in the statement that per- 
sons rarely die of the disease with which they suffer. Secondary infee- 



166 



SPECIFIC INFECTIOUS DISEASES. 



tions, or, as we are apt to call them in hospital work, terminal infections, 
carry off many of the incurable cases in the wards. Flexner * has analyzed 
255 cases of chronic renal and cardiac disease in which complete bacterio- 
logical examinations were made at autopsy. Excluding tuberculous infec- 
tion, 213 gave positive and 42 negative results. 

The infections may be local or general. The former are extremely 
common, and are found in a large proportion of all cases of Bright's disease, 
arterio-sclerosis, heart-disease, cirrhosis of the liver, and other chronic dis- 
orders. Affections of the serous membranes (acute pleurisy, acute peri- 
carditis, or peritonitis), meningitis, and endocarditis are the most frequent 
lesions. It is perhaps safe to say that the majority of cases of advanced 
arterio-sclerosis and of Bright's disease succumb to these intercurrent infec- 
tions. The infective agents are very varied. The streptococcus pyogenes 
is perhaps the most common, but the pneumococcus, staphylococcus aureus, 
the bacillus proteus, the gonococcus, the gas bacillus, and the bacillus pyo- 
cyaneus are also met with. 

Particular mention may be here made of the terminal form of acute 
miliary tuberculosis. It is surprising in how many instances of arterio- 
sclerosis, of chronic heart-disease, of Bright's disease, and more particu- 
larly of cirrhosis of the liver, the fatal event is determined by an acute 
tuberculosis of the peritonaeum or pleura. 

The general terminal infections are somewhat less common. Of 85 cases 
of chronic renal disease in which Flexner found micro-organisms at au- 
topsy, 38 exhibited general infections; of 48 cases of chronic cardiac disease, 
in 14 the distribution of bacteria was general. The blood-serum of persons 
suffering from advanced chronic disease was found by him to be less de- 
structive to the staphylococcus aureus than normal human serum. Other 
diseases in which general terminal infection may occur are Hodgkin's dis- 
ease, leukaemia, and chronic tuberculosis. 

And, lastly, probably of the same nature is the terminal entero-colitis 
so frequently met with in chronic disorders. 

XIX. RHEUMATIC FEVER. 

Definition. — An acute, non-contagious fever, dependent upon an un- 
known infective agent, and characterized by multiple arthritis and a marked 
tendency to inflammation of the fibrous tissues. 

Etiology.— Distribution and Prevalence. — It prevails in temperate and 
humid climates. Church has collected interesting statistics on this point. 
Oddly enough, the two countries with the highest admission in the army per 
thousand of strength — Egypt, 7.02, and Canada, 6.26 — have climates the 
most diverse. The returns, however, from Canada for the six years from 
1886 to 1892 are perhaps more correct, 2.83 per thousand of strength. The 
death-rate for the five years 1881-85 in Great Britain was 97 per million. 
In the United States there are no satisfactory statistics; the disease is not 



* Jour. Exp. Med., i, 1896. 



RHEUMATIC FEVER. 



167 



dealt with in the last Census Eeport as a cause of death. So far as my 
personal observation goes, it certainly seemed to be more prevalent in Mon- 
treal than in Philadelphia or Baltimore. The general impression is that 
the disease prevails more in the British Isles than elsewhere; but, as Church 
remarks, the returns are very imperfect (this holds good everywhere), and 
probably the death-rate from rheumatic fever itself is very much lower 
than the figures would indicate, as very many different diseases are grouped 
under this heading. In Norway, where cases of rheumatic fever are 
notified, there were for the four years 1888- 92 13,651 cases, with 250 
deaths. 

Season.- — In London the cases reach the maximum in the months of 
September and October. In the Montreal General Hospital Bell's statis- 
tics of 456 cases show that the largest number was admitted in February, 
March, and April. Kewsholme has brought forward statistics to show that 
the disease prevails most in the dry years or a succession of such, and is 
specially prevalent when the subsoil water is abnormally low and the tem- 
perature of the earth high. 

Age. — Young adults are most frequently affected, but the disease is by 
no means uncommon in children between the ages of ten and fifteen 
years. Sucklings are rarely attacked. Milton Miller has analyzed 19 
undoubted cases. The cases have to be distinguished from a totally 
different affection, the pyogenic arthritis of infants. The following 
age table is based upon 456 cases admitted to the Montreal General 
Hospital: Under fifteen years, 4.38 per cent; from fifteen to twenty- 
five years, 48.68 per cent; from twenty-five to thirty-five years, 25.87 per 
cent; from thirty-five -to forty-five years, 13.6 per cent; above forty-five 
years, 7.4 per cent. Of the 655 cases analyzed by Whipham for the Col- 
lective Investigation Committee of the British Medical Association, only 
32 cases occurred under the tenth year and 80 per cent between the twen- 
tieth and fortieth year. These figures scarcely give the ratio of cases in 
children. 

Sex. — If all ages are taken, males are affected oftener than females, 
In the Collective Investigation Eeport there were 375 males and 279 
females. Up to the age of twenty, however, females predominate. Be- 
tween the ages of ten and fifteen girls are more prone to the disease. 

Heredity. — It is a deeply grounded belief with the public and the pro- 
fession that rheumatism is a family disease, but Church thinks the evidence 
is still imperfect. Its not rare occurrence in several members of the same 
family is used by those who believe in the infectious origin as an argument 
in favor of its being a house disease. 

The occupations which necessitate exposure to cold and great changes 
of temperature predispose strongly to rheumatic fever. The disease is met 
with oftenest in drivers, servants, bakers, sailors, and laborers. 

Chill. — Exposure to cold, a wetting, or a sudden change of temperature 
are among the most important factors in determining the onset of an 
attack. 

Immunity is not afforded by an attack; on the contrary, as in pneu- 
monia, one attack predisposes the subject to the disease. 



168 



SPECIFIC INFECTIOUS DISEASES. 



Rheumatic Fever as an Acute Infectious Disease. — (a) General Evidence. 
— Elieumatic fever, as ISTeAvsholme has shown, occurs in epidemics without 
regular periodicity, recurring at intervals of three, four, or six years, and 
varying much in intensity. A severe epidemic is apt to be followed by 
two or three mild outbreaks. " The curves of the mortality statistics . . . 
approximate very closely to those of pyaemia, puerperal fever, and erysipe- 
las, diseases which are certainly associated with specific micro-organisms " 
(Church). The constancy also of the seasonal variations is an additional 
support to this view. 

(b) Clinical Features. — Physicians have long been impressed with the 
striking similarity of the symptoms of rheumatic fever to those of septic 
infection. In the character of the fever, the mode of involvement of the 
joints, the tendency to relapse, the sweats, the anaemia, the leucocytosis, and, 
above all, the great liability to endocarditis and involvement of the serous 
membranes, acute rheumatic fever resembles pyaemia very closely, and 
may, indeed, be taken as the very type of an acute infection. But, as 
Stephen Mackenzie remarks, acute rheumatism should be considered not 
simply from the point of view of the rheumatic polyarthritis of the adult, 
but as a whole in its manifestations at different periods of life; yet even 
from this standpoint the multiform manifestations of the rheumatic poison 
in childhood and young adults may very reasonably be referred to the effect 
of the toxines of micro-organisms. 

(c) Special Evidence. — The bacteriology of the disease is still under 
discussion. Singer's results have not been confirmed. Achalme has found 
a bacillus in the blood during life. Poynton and Paine have isolated a 
diplococcus from 16 cases, which is apparently identical with the organism 
described by Triboulet and Wassermann, and have produced experimentally 
in rabbits a painful polyarthritis with fever. Eecently they have obtained 
the organism from the rheumatic nodules in pure culture and have repro- 
duced in the rabbit valvulitis, pericarditis, and polyarthritis. Special 
stress has been laid upon the tonsils as the point of entrance of the infec- 
tion, as it has long been known that tonsillitis was a very frequent initial 
symptom — 28 out of 66 cases in Singer's series. Indeed, some have gone 
so far as to say that there is always a primary infective trouble in the 
lacunae of the tonsils, to which the rheumatic fever is secondary, arising 
from the absorption of microbes or their products. 

Other views as to the nature of rheumatism are the metabolic or chemical: 
that it depends upon a morbid material produced within the system in 
defective processes of assimilation. It has been suggested that this mate- 
rial is lactic acid (Prout) or certain combinations with lactic acid (Latham). 
Our knowledge of the chemical relations of the various products produced 
in the regressive nutritive changes is too limited to warrant much reliance 
upon these views. Eichardson claims to have produced rheumatism by in- 
jecting lactic acid and by its internal administration. 

Nervous Theory of Acute Rheumatism. — This was specially advocated 
by the late Dr. J. K. Mitchell, of Philadelphia. According to this view, 
either the nerve centres are primarily affected by cold and the local lesions 
are really trophic in character, or the primary nervous disturbance leads 



RHEUMATIC FEVER. 



169 



to errors in metabolism and the accumulation of lactic acid in the system. 
The advocates of this view regard as analogous the arthropathies of myelitis, 
locomotor ataxia, and chorea. 

Morbid Anatomy. — There are no changes characteristic of the dis- 
ease. The affected joints show hyperemia and swelling of the synovial 
membranes and of the ligamentous tissues. There may be slight erosion 
of the cartilage. The fluid in the joint is turbid, albuminous in character, 
and contains leucocytes and a few fibrin flakes. Pus is very rare in uncom- 
plicated cases. Rheumatism rarely proves fatal, except when there are 
serious complications, such as pericarditis, endocarditis, myocarditis, pleu- 
risy, or pneumonia. The conditions found show nothing peculiar, nothing 
to distinguish them from other forms of inflammation. In death from 
hyperpyrexia no special changes occur. The blood usually contains an 
excessive amount of fibrin. In the secondary rheumatic inflammations, 
as pleurisy and pericarditis, various pus organisms have been found, pos- 
sibly the result of a mixed infection. 

Symptoms. — As a rule, the disease sets in abruptly, but it may be 
preceded by irregular pains in the joints, slight malaise, sore throat, and 
particularly by tonsillitis. A definite rigor is uncommon; more often 
there is slight chilliness. The fever rises quickly, and with it one or more 
of the joints become painful. Within twenty-four hours from the onset, 
the disease is fully manifest. The temperature range is from 102° to 
104°. The pulse is frequent, soft, and usually above 100. The tongue is 
moist, and rapidly becomes covered with a white fur. There are the ordi- 
nary symptoms associated with an acute fever, such as loss of appetite, 
thirst, constipation, and a scanty, highly acid, highly colored urine. In a 
majority of the cases there are profuse, very acid sweats, of a peculiar sour 
odor. Sudaminal and miliary vesicles are abundant, the latter usually sur- 
rounded by a minute ring of hyperemia. The mind is clear, except in 
the cases with hyperpyrexia. The affected joints are painful to move, 
soon become swollen and hot, and present a reddish flush. The knees, 
ankles, elbows, and wrists are the joints usually attacked, not together, 
but successively. For example, if the knee is first affected, the redness 
may disappear from it as the wrists become painful and hot. The disease 
is seldom limited to a single articulation. The amount of swelling is vari- 
able. Extensive effusion into a joint is rare, and much of the enlargement 
5s due to the infiltration of the periarticular tissues with serum. The 
swelling may be limited to the joint proper, but in the wrists and ankles 
it sometimes involves the sheaths of the tendons and produces great en- 
largement of the hands and feet. Corresponding joints are often affected. 
In attacks of great severity every one of the larger joints may be involved. 
The vertebral, sterno-clavicular, and phalangeal articulations are less often 
inflamed in acute than in gonorrheal rheumatism. Perhaps no disease is 
more painful than acute polyarthritis. The inability to change the posture 
without agonizing pain, the drenching sweats, the prostration and utter 
helplessness, combine to make it one of the most distressing of febrile 
affections. A special feature of the disease is the tendency of the inflamma- 
tion to subside in one joint while increasing with great intensity in another. 



170 



SPECIFIC INFECTIOUS DISEASES. 



The temperature range in an ordinary attack is between 102° and 104°. 
It is peculiarly irregular, with marked remissions and exacerbations, de- 
pending very much upon the intensity and extent of the articular inflam- 
mation. Defervescence is usually gradual. The profuse sweats materially 
influence the temperature curve. If a two-hourly chart is made and ob- 
servations upon the sweats are noted, the remissions will usually be found 
coincident with the sweats. The perspiration is sour-smelling and acid at 
first; but, when persistent, becomes neutral or even alkaline. 

The blood is profoundly and rapidly altered in acute rheumatism. 
There is, indeed, no acute febrile disease in which the anaemia occurs 
with greater rapidity. There is a well-marked leucocytosis. 

With the high fever a murmur may often be heard at the apex region. 
Endocarditis is also a common cause of an apex bruit. The heart should 
be carefully examined at the first visit and subsequently each day. 

The urine is, as a rule, reduced in amount, of high density and high 
color. It is very acid, and, on cooling, deposits urates. The chlorides 
may be greatly diminished or even absent. Febrile albuminuria is not 
uncommon. 

The saliva may become acid in reaction and is said to contain an excess 
of sulphocyanides. 

Subacute Rheumatism. — This represents a milder form of the dis- 
ease, in which all the symptoms are less pronounced. The fever rarely rises 
above 101°; fewer joints are involved; and the arthritis is less intense. 
The cases may drag on for weeks or months, and the disease may finally 
become chronic. It should not be forgotten that in children this mild or 
subacute form may be associated with endocarditis or pericarditis. 

Complications. — These are important and serious. 

(1) Hyperpyrexia. — The temperature may rise rapidly a few days after 
the onset, and be associated with delirium; but not necessarily, for the 
temperature may rise to 108° or, as in one of Da Costa's cases, 110°, with 
out cerebral symptoms. Hyperpyrexia is most common in first attacks, 
57 of 107 cases (Church). It is most apt to occur during the second week. 
The delirium may precede or follow the onset of the hyperpyrexia. As a 
rule, with the high fever, the pulse is feeble and frequent, the prostration 
is extreme, and finally stupor supervenes. 

(2) Cardiac Affections. — (a) Endocarditis, the most frequent and serious 
complication, occurs in a considerable percentage of all cases. Of 889 cases, 
494 had signs of old or recent endocarditis (Church). The liability to 
endocarditis diminishes as age advances. It increases directly with the 
number of attacks. Of 116 cases in the first attack, 58.1 per cent had endo- 
carditis, 63 per cent in the second attack, and 71 per cent in the third 
attack (Stephen Mackenzie). The mitral segments are most frequently in- 
volved and the affection is usually of the simple, verrucose variety. Ulcer- 
ative endocarditis in the course of acute rheumatism is very rare. Of 209 
cases of this disease which I analyzed, in only 24 did the symptoms of a 
severe endocarditis arise during the progress of acute or subacute rheuma- 
tism. This complication, in itself, is rarely dangerous. It produces few 
symptoms and is usually overlooked. Unhappily, though the valve at the 



RHEUMATIC FEVER. 



171 



time may not be seriously damaged, the inflammation starts changes which 
lead to sclerosis and retraction of the segments, and so to chronic valvular 
disease. Venous thrombosis is an occasional complication. 

(b) Pericarditis may occur independently of or together with endocar- 
ditis. It may be simple fibrinous, sero-fibrinous, or in children purulent. 
Clinically we meet it more frequently in connection with rheumatism 
than all other affections combined. The physical signs are very character- 
istic. The condition will be fully described under its appropriate section. 
A peculiar form of delirium may develop during the progress of rheumatic 
pericarditis. 

(c) Myocarditis is most frequent in connection with endo-pericardial 
changes. As Sturges insisted, the term carditis is applicable to many cases. 
The anatomical condition is a granular or fatty degeneration of the heart- 
muscle, which leads to weakening of the walls and to dilatation. It is not, 
I think, nearly so common as the other cardiac affections. S. West has re- 
ported instances of acute dilatation of the heart in rheumatic fever, in one 
of which marked fatty changes were found in the heart-fibres. 

(3) Pulmonary Affections. — Pneumonia and pleurisy occurred in 9.94 
per cent of 3,433 cases (Stephen Mackenzie). They frequently accompany 
the cases of endo-pericarditis. According to Howard's analysis of a large 
number of cases, there were pulmonary complications in only 10.5 per 
cent of cases of rheumatic endocarditis; in 58 per cent of cases of peri- 
carditis; and in 71 per cent of cases of endo-pericarditis. Congestion of 
the lung is occasionally found, and in several cases has proved rapidly 
fatal. 

(4) Nervous Complications. — These are due, in part, to the hyper- 
pyrexia and in part to the special action upon the brain of the toxic agent 
of the disease. They may be grouped as follows: (a) Delirium. This is 
usually associated with the hyperpyrexia, but may be independent of it. 
It may be active and noisy in character; more rarely a low muttering 
delirium, passing into stupor and coma. Special mention must be made 
of the delirium which occurs in connection with rheumatic pericarditis. 
Delirium, too, may be excited by the salicylate of soda, either shortly after 
its administration, or more commonly a week or ten days later, (b) Com a, 
which is more serious, may occur without preliminary delirium or con- 
vulsions, and may prove rapidly fatal. Certain of these cases are associ- 
ated with hyperpyrexia; but Southey has reported the case of a girl who, 
without previous delirium or high fever, became comatose, and died in less 
than an hour. A certain number of such cases, as those reported by Da 
Costa, have been associated with marked renal changes and were evidently 
uraemic. The coma may supervene during the attack, or after convales- 
eence has set in. (c) Convulsions are less common, though they may precede 
the coma, Of 127 observations cited by Besnier, there were 37 of delirium, 
only 7 of convulsions, 17 of coma and convnlsions, 54 of delirium, coma, 
and convulsions, and 3 of oilier varieties (Howard), (d) Chorea. The 
relations of this disease and rheumatism will be subsequently discussed. 
It is sufficient here to say that in only 88 out of 554 cases which I have 
analyzed from the Infirmary for Diseases of the Nervous System, Philfc- 

11 



172 



SPECIFIC INFECTIOUS DISEASES. 



delphia, were chorea and rheumatism associated. It is most apt to develop 
in the slighter attacks in childhood, (e) Meningitis is extremely rare, 
though undoubtedly it does occur. It must not be forgotten that in ulcer- 
ative endocarditis, which is occasionally associated with acute rheumatism, 
meningitis is frequent. (/) Polyneuritis has been described. 

(5) Cutaneous Affections. — Sweat-vesicles have already been mentioned 
as extremely common. A red miliary rash may also develop. Scarlatini- 
form eruptions are occasionally seen. Purpura, with or without urticaria, 
may occur, and various forms of erythema. It is doubtful whether the 
cases of extensive purpura with urticaria and arthritis — peliosis rheumatica 
— belong truly .to acute rheumatism. 

(6) Rheumatic Nodules. — These curious structures, in the form of small 
subcutaneous nodules attached to the tendons and fasciee, have been known 
for some years; but special attention has been paid to them of late, since 
their careful study by Barlow and Warner. While not so common in this 
country as in England, the cases are by no means infrequent (Futcher. 
J. H. H. Bulletin, 1895). They vary in size from a small shot to a large 
pea, and are most numerous on the fingers, hands, and wrists. They also 
occur about the elbows, knees, the spines of the vertebrae, and the scapula?. 
They are not often tender. They do not necessarily come on during the 
fever, but may be found on its decline, or even independently altogether 
of an acute attack. The nodules may grow with great rapidity and usually 
last for weeks or months. They are more common in children than in 
adults, and in the former their presence may be regarded as a positive indi- 
cation of rheumatism. They have been noted particularly in association 
with severe and chronic rheumatic endocarditis. Subcutaneous nodules 
occur also in migraine, gout, and arthritis deformans. Histologically they 
are made up of round and spindle-shaped cells. In addition to these firm, 
hard nodules, there occur in rheumatism and in chronic vegetative endo- 
carditis remarkable small bodies, which have been called by Fereol " noclo- 
sites cutanees ephemeres." In a case of chronic vegetative endocarditis 
(without arthritis), which I saw with Dr. J. K. Mitchell, there were, in 
addition to occasional elevated spots resembling urticaria, areas of infiltra- 
tion in the skin, from two to three lines in diameter, not elevated, but pale 
pink, and exquisitely tender and painful even without being touched. 

The course of acute rheumatism is extremely variable. It is, as Austin 
Flint first showed, a self-limited disease, and it is not probable that medi- 
cines have any special influence upon its duration or course. Gull and 
Sutton, who likewise studied a series of 62 cases without special treatment, 
arrived at the same conclusion. 

Sudden death in rheumatic fever is due most frequently to myocarditis. 
Herringham has reported a case in which on the fourteenth day there was 
fatty degeneration and acute inflammation of the myocardium. In a few 
rare cases it results from embolism. I saw one case at the Montreal Gen- 
eral Hospital in which we thought possibly the sudden death was due to 
Fuller's alkaline treatment, which had been kept up by mistake. There was 
slight endocarditis but no myocardial changes. Alarming svmptoms of 
depression sometimes follow excessive doses of the salicylate of soda. 



RHEUMATIC FEVER. 



173 



Diagnosis. — Practically, the recognition of acute rheumatism is very 
easy; but there are several affections which, in some particulars, closely 
resemble it. 

(1) Multiple Secondary Arthritis. — Under this term may be embraced 
the various forms of arthritis which come on or follow in the course of the 
infective diseases, such as gonorrhoea, scarlet fever, dysentery, and cerebro- 
spinal meningitis. Of these the gonorrhceal form will receive special con- 
sideration and is the type of the entire group. 

(2) Septic Arthritis, which develops in the course of pyaemia from any 
cause, and particularly in puerperal fever. No hard and fast line can be 
drawn between these and the cases in the first group; but the inflammation 
rapidly passes on to suppuration and there is more or less destruction of 
the joints. The conditions under which the arthritis occurs give a clew 
at once to the nature of the case. Under this section may also be men- 
tioned: 

(a) Acute necrosis or acute osteo-myelitis, occurring in the lower end 
of the femur, or in the tibia, and which may be mistaken for acute rheu- 
matism. Sometimes, too, it is multiple. The greater intensity of the local 
symptoms, the involvement of the epiphyses rather than the joints, and 
the more serious constitutional disturbances are points to be considered. 
The condition is unfortunately often mistaken for acute arthritis, and, as 
the treatment is essentially surgical, the error is one which may cost the life 
of the patient. 

(b) The acute arthritis of infants must be distinguished from rheuma- 
tism. It is a disease which is usually confined to one joint (the hip or 
knee), the effusion in which rapidly becomes purulent. The affection is 
most common in sucklings and is undoubtedly pysemic in character. It 
may also occur in the gonorrhceal ophthalmia or vaginitis of the new- 
born, as pointed out by Clement Lucas. 

(3) Gout. — While the localization in a single, usually a small, joint, the 
age, the history, and the mode of onset are features which enable us to recog- 
nize acute gout, there are in this country many cases of acute arthritis, 
called rheumatic fever, which are in reality gout. The involvement of sev- 
eral of the larger joints is not so infrequent in gout, and unless tophi are 
present, or unless a very accurate analysis of the urine is made, the diagnosis 
may be difficult. 

Treatment. — The bed should have a smooth, soft, yet elastic mattress. 
The patient should wear a flannel night-gown, which may be opened all the 
way down the front and slit along the outer margin of the sleeves. Three 
or four of these should be made, so as to facilitate the frequent changes 
required after the sweats. He may wear also a light flannel cape about the 
shoulders. He should sleep in blankets, not in sheets, so as to reduce the 
liability to catch cold and obviate the unpleasant clamminess consequent 
upon heavy sweating. Chambers insisted that the liability to endocarditis 
and pericarditis was much reduced when the patients were in blankets. 

Milk is the most suitable diet. It may be diluted with alkaline min- 
eral waters. Lemonade and oatmeal or barley water should be freely given. 
The thirst is usually great and may be fully satisfied. There is no objec- 



174 



SPECIFIC INFECTIOUS DISEASES. 



tion to broths and soups if the milk is not well borne. The food should 
be given at short and stated intervals. As convalescence is established a 
fuller diet may be allowed, but meat should be used sparingly. 

The local treatment is of the greatest importance. It often suffices to 
wrap the affected joints in cotton. If the pain is severe, hot cloths may 
be applied, saturated with Fuller's lotion (carbonate of soda, 6 drachms; 
laudanum, 1 oz.; glycerine, 2 oz.; and water, 9 oz.). Tincture of aconite 
or chloral may be employed in an alkaline solution. Chloroform liniment 
is also a good application. Fixation of the joints is of great service in allay- 
ing the pain. I have seen, in a German hospital, the joints enclosed in 
plaster of Paris, apparently with great relief. Splints, padded and bandaged 
with moderate firmness, will often be found to relieve pain. Friction is 
rarely well borne in an acutely inflamed joint. Cold compresses are much 
used in Germany. The application of blisters above and below the joint 
often relieves the pain. This method, which was used so much a few years 
ago, is not to be compared with the light application of the Paquelin 
thermo-cautery. 

The drug treatment of acute rheumatism is still far from satisfactory, 
though the introduction of the salicyl compounds has been a great boon. 
Pribram's exhaustive consideration of the question, extending over some 
67 pages (Nothnagel's Handbuch, Bd. v), in which he discusses some 75 
drugs and measures, indicates perhaps better than anything else that the 
therapeutics of the disease are still far from satisfactory. 

Treatment with the Salicyl Compounds. — Salicin, introduced in 1876 by 
Maclagan, may be used in doses of 20 grains every hour or two until the 
pain is relieved. It has the advantage of being less depressing than the 
salicylate of soda. It is also perhaps the best drug to use for children. 
Salicylic acid, 15 to 20 grains, may be given every two hours in acute cases 
until the pain is relieved. It is best given in capsules. Salicylate of soda, 
20-grain doses every two hours, is perhaps the best of the drugs for gen- 
eral use in the acute rheumatism of adults. After the pain has been 
relieved, the drug should be given every four or five hours until the tem- 
perature begins to fall. The potassium bicarbonate may be given with it. 
Oil of wintergreen, 20 minims every two hours in milk, may be used if the 
salicylate of soda disagrees. There are many other salicyl compounds in- 
troduced of late, but the best results are obtained from the use of one or 
other of the above-named preparations. There can be no question as to 
their efficacy in relieving the pain in the disease. A majority of observers 
agree that they also protect the heart, shorten the course, and render 
relapse less likely. 

The Alkaline Treatment. — Potassium bicarbonate may be given in half- 
drachm doses every three hours with the salicylic acid or salicin. Fuller's , 
plan was to give a drachm and a half of the sodium bicarbonate with half 
a drachm of potassium acetate in three ounces of water, rendered effer- 
vescent at the time of administration by half a drachm of citric acid or an 
ounce of lemon-juice. When the urine is alkaline the amount may be 
reduced. 

The heart should be watched carefully during the administration of 
full doses of the alkalies. 



CHOLERA ASIATICA. 



175 



Opinion favors the view that with the alkaline treatment endocarditis is 
less frequent, but the disease is not cut short, nor is the pain allayed. The 
truth is there are certain cases of rheumatic fever that resist all forms of 
treatment, and persist for weeks, sometimes with recrudescences or relapses 
of great severity. 

To allay the pain opium may be given in the form of Dover's powder, 
or morphia hypodermically. Antipyrin, antifebrin, and phenacetin are 
useful sometimes for the purpose. During convalescence iron is indicated 
in full doses, and quinine is a useful tonic. Of the complications, hyper- 
pyrexia should be treated by the cold bath or the cold pack. The treat- 
ment of endocarditis and pericarditis and the pulmonary complications 
will be considered under their respective sections. 

To prevent and arrest endocarditis Caton urges the use of a series of 
small blisters along the course of the third, fourth, fifth, and sixth inter- 
costal nerves of the left side, applied one at a time and repeated at differ- 
ent points. Potassium or sodium iodide is given in addition to the salicyl- 
ates. The patients are kept in bed for about six weeks. 



XX. CHOLERA ASIATICA. 

Definition. — A specific, infectious disease, caused by the comma ba- 
cillus of Koch, and characterized clinically by violent purging and rapid 
collapse. 

Historical Summary. — Cholera has been endemic in India from a 
remote period, but only within the present century has it made inroads into 
Europe and America. An extensive epidemic occurred in 1832, in which 
year it was brought in immigrant ships from Great Britain to Quebec. It 
travelled along the lines of traffic up the Great Lakes, and finally reached 
as far west as the military posts of the upper Mississippi. In the same 
year it entered the United States by way of New York. There were re- 
currences of the disease in 1835-'36. In 1848 it entered the country through 
New Orleans, and spread widely up the Mississippi Valley and across the 
continent to California. In 1849 it again appeared. In 1854 it was intro- 
duced by immigrant ships into New York and prevailed widely through- 
out the country. In 1866 and in 1867 there were less serious epidemics. 
In 1873 it again appeared in the United States, but did not prevail widely. 
In 1884 there was an outbreak in Europe, and again in 1892 and 1893. 
Although occasional cases have been brought by ship to the quarantine 
stations in this country, the disease has not gained a foothold here since 
1873. 

Etiology. — In 1884 Koch announced the discovery of the specific 
organism of this disease. Subsequent observations have confirmed his 
statement that the comma bacillus, as it is termed, occurs constantly in 
the true cholera, and in no other disease. It lias the form of a slightly 
bent rod, which is thicker, but not more than about half the length of the 
tubercle bacillus, and sometimes occurs in corkscrew-like or S forms. It is 
not a true bacillus, but really a spirochete. The organisms grow upon a 
great variety of media and display distinctive and characteristic appear- 



176 



SPECIFIC INFECTIOUS DISEASES. 



ances. Koch found them in the water-tanks in India, and they were isolated 
from the Elbe water during the Hamburg epidemic of 1892. During epi- 
demics virulent bacilli may be found in the faeces of healthy persons. The 
bacilli are found in the intestine, in the stools from the earliest period of 
the disease, and very abundantly in the characteristic rice-water evacua- 
tions, in which they may be seen as an almost pure culture. They very 
rarely occur in the vomit. Post mortem, they are found in enormous num- 
bers in the intestine. In acutely fatal cases they do not seem to invade the 
intestinal wall, but in those with a more protracted course they are found 
in the depths of the glands and in the still deeper tissues. Experimental 
animals are not susceptible to cholera germs administered per os. But 
if introduced after neutralization of the gastric contents, and if kept in 
contact with the intestinal mucosa by controlling peristalsis with opium, 
guinea-pigs succumb after showing cholera-like symptoms. The intestines 
are filled with thin, watery contents, containing comma bacilli, in almost 
pure culture. 

Cholera Toxine. — Koch in his studies of cholera failed to find the 
spirilla in the internal organs. He concluded that the constitutional symp- 
toms of the disease resulted from the absorption of toxic bodies from the 
intestine. In old cholera cultures ptomaines are contained; these probably 
have nothing to do with the intoxication of human cholera. R. Pfeiffer 
has shown that the cholera toxine is intimately associated with the proteid 
of the bacterial cells, and, being of a very labile nature, cannot be separated. 
Dead cultures are toxic; and the symptoms produced by the introduction of 
even minimal amounts are often comparable with those of the algid stage 
of cholera asiatica. The symptoms develop very rapidly, and death often 
results in eight to twelve hours; in non-fatal cases recovery is often equally 
as rapid. The intracellular cholera toxine is poisonous to animals if intro- 
duced into the blood, peritoneal cavity, or subcutaneous tissues. ISTo ab- 
sorption takes place from the intestine unless the epithelial layer has been 
injured. 

Immunity. — Lazarus found that the blood-serum of human beings who 
had recovered from cholera contained an antidotal substance which would 
prevent the fatal result of intraperitoneal injections of cholera vibrios in 
guinea-pigs. E. Pfeiffer showed, contrary to Lazarus, that this substance 
was not of the nature of an antitoxine, but was actively bactericidal, and 
caused rapid disintegration of the introduced bacilli. The blood-serum 
of animals rendered immune to the bacillus contains this body. Upon its 
presence depends the success of the " Pfeiffer serum reaction " for the 
identification of the true cholera vibrio and its differentiation from all other 
forms which resemble it. Haffkine has carried out immunizing injections 
of cholera cultures in India on a large scale with very promising results. 

Modes of Infection. — As in other diseases, individual peculiarities count 
for much, and during epidemics virulent cholera bacilli have been isolated 
from the normal stools of healthy men. Cholera cultures have also been 
swallowed with impunity. 

The disease is not highly contagious; physicians, nurses, and others in 
close contact with patients are not often affected. On the other hand, 



CHOLERA ASIATICA. 



177 



washerwomen and those who are brought into very close contact with the 
linen of the cholera patients, or with their stools, are particularly prone to 
catch the disease. There have been several instances of so-called " labora- 
tory cholera," in which students, having been accidentally infected while 
working with the cultures, have developed the disease, and at least one 
death has resulted from this cause. 

Vegetables which have been washed in the infected water, particularly 
lettuces and cresses, may convey the disease. Milk may also be contami- 
nated. The bacilli live on fresh bread, butter, and meat, for from 
six to eight days. In regions in which the disease prevails the possibil- 
ity of the infection of food by flies should be borne in mind, since it has 
been shown that the bacilli may live for at least three days in their intes- 
tines. 

Infection through the air is not to be much dreaded, since the germs 
when dried die rapidly. 

The disease is propagated chiefly by contaminated water used for drink- 
ing, cooking, and washing. The virulence of an epidemic in any region 
is in direct proportion to the imperfection of its water-supply. In India 
the demonstration of the connection between drinking-water and cholera 
infection is complete. The Hamburg epidemic is a most remarkable illus- 
tration. The unfiltered water of the Elbe was the chief supply, although 
taken from the river in such a situation that it was of necessity directly 
contaminated by sewage. It is not known accurately from what source the 
contagion came, whether from Russia or from France, but in August, 1892, 
there was a sudden explosive epidemic, and within three months nearly 
18,000 persons were attacked, with a mortality of 42.3 per cent. The neigh- 
boring city of Altona, which also took its water from the Elbe, but which 
had a thoroughly v eil-equipped modern nitration system, had in the same 
period only 516 cases. 

Two main types of epidemics of cholera are recognized: the first, in 
which many individuals are attacked simultaneously, as in the Hamburg 
outbreak, and in which no direct connection can be traced between the 
individual cases. In this type there is widespread contamination of the 
drinking-water. In the other the cases occur in groups, so-called cholera 
nests; individuals are not attacked simultaneously but successively. A 
direct connection between the cases may be very difficult to trace. Again, 
both these types may be combined, and in an epidemic which has started 
in a widespread infection through water, there may be other outbreaks, 
which are examples of the second or chain-like type. 

Pettenkofer, on the other hand, denies the truth of this drinking- 
water theory, and maintains that the conditions of the soil are of the great- 
est importance; particularly a certain porosity, combined with moisture 
and contamination with organic matter, such as sewage. He holds that 
germs develop in the subsoil moisture during the warm months, and that 
they rise into the atmosphere as a miasm. 

The disease always follows the lines of human travel. In India it has, 



178 



SPECIFIC INFECTIOUS DISEASES. 



in many notable cases, been widely spread by pilgrims. It is carried also 
by caravans and in ships. It is not conveyed through the atmosphere. 

Places situated at the sea-level are more prone to the disease than inland 
towns. In high altitudes the disease does not prevail so extensively. A 
high temperature favors the development of cholera, but in Europe and 
America the epidemics have been chiefly in the late summer and in the 
autumn. 

The disease affects persons of all ages. It is particularly prone to attack 
the intemperate and those debilitated by want of food and by bad surround- 
ings. Depressing emotions, such as fear, undoubtedly have a marked influ- 
ence. It is doubtful whether an attack furnishes immunity against a 
second one. 

Morbid Anatomy. — There are no characteristic anatomical changes 
in cholera; but a post-mortem diagnosis of the nature of the disease could 
be made by any competent bacteriologist, as the micro-organisms are spe- 
cific and distinctive. The body has the appearances associated with pro- 
found collapse. There is often marked post-mortem elevation of tempera- 
ture. The rigor mortis sets in early and may produce displacement of the 
limbs. The lower jaw has been seen to move and the eyes to rotate. Vari- 
ous movements of the arms and legs have also been noted. The blood is 
thick and dark, and there is a remarkable diminution in the amount of its 
water and salts. The peritonaeum is sticky, and the coils of intestines are 
congested and look thin and shrunken. There is nothing special in the 
appearance of the stomach. The small intestine usually contains a turbid 
serum, similar in appearance to that which was passed in the stools. The 
mucosa is, as a rule, swollen, and in very acute cases slightly hyperamiic; 
later the congestion, which is not uniform, is more marked, especially 
about the Peyer's patches. Post mortem the epithelial lining is sometimes 
denuded, but this is probably not a change which takes place freely during 
life. In the stools, however, large numbers of columnar epithelial cells have 
been described by Horner and others. The bacilli are found in the con- 
tents of the intestine and in the mucous membrane. The spleen is usually 
small. The liver and kidneys show cloudy swelling, and the latter extensive 
coagulation-necrosis and destruction of the epithelial cells. The heart is 
flabby; the right chambers are distended with blood and the left chambers 
are usually empty. The lungs are collapsed, and congested at the bases. 

The above appearances are those met with in cases which prove rapidly 
fatal. When the patient survives and death occurs during reaction, there 
may be more definite inflammatory appearances in the intestines leading 
to extensive necrosis and fibrinous exudation, and more pronounced changes 
in the kidneys and liver. 

In the acute cases the rice-water discharges contain the vibrios in prac- 
tically pure cultures; at a somewhat later stage other bacteria make their 
appearance, while in the stage of cholera-typhoid the comma bacilli are 
demonstrated with difficulty. 

Symptoms. — A period of incubation of uncertain length, probably 
not more than from two to five clays, precedes the development of the 
symptoms. 



CHOLERA ASIATICA. 



179 



Three stages may be recognized in the attack: the preliminary diar- 
rhoea, the collapse stage, and the period of reaction. 

(a) The preliminary diarrhoea may set in abruptly without any previous 
indications. More commonly there are, for one or two days, colicky pains 
in the abdomen, with looseness of the bowels, perhaps vomiting, with head- 
ache and depression of spirits. There may be no fever. 

(b) Collapse Stage. — The diarrhoea increases, or, without any of the 
preliminary symptoms, sets in with the greatest intensity, and profuse 
liquid evacuations succeed each other rapidly. There are in some instances 
griping pains and tenesmus. More commonly there is a sense of exhaustion 
and collapse. The thirst becomes extreme, the tongue is white; cramps of 
great severity occur in the legs and feet. Within a few hours vomiting 
sets in and becomes incessant. The patient rapidly sinks into a condition 
of collapse, "the features are shrunken, the skin has an ashy gray hue, the 
eyeballs sink in the sockets, the nose is pinched, the cheeks are hollow, 
the voice becomes husky, the extremities are cyanosed, and the skin is shriv- 
elled, wrinkled, and covered with a clammy perspiration. The temperature 
sinks. In the axilla or in the mouth it may be from five to ten degrees 
below normal, but in the rectum and in the internal parts it may be 103° 
or 104°. The pulse becomes extremely feeble and flickering, and the patient 
gradually passes into a condition of coma, though consciousness is often 
retained until near the end. 

The faeces are at first yellowish in color, from the bile pigment, but 
soon they become grayish white and look like turbid whey or rice-water; 
whence the term " rice-water stools." There are found in them numerous 
small flakes of mucus and granular matter, and at times blood. The re- 
action is usually alkaline. The fluid contains albumin and the chief min- 
eral ingredient is chloride of sodium. Microscopically, mucus and epithelial 
cells and innumerable bacteria are seen, the majority of the latter being 
the comma bacilli. 

The condition of the patient is largely the result of the concentration 
of the blood consequent upon the loss of serum in the stools. There is 
almost complete arrest of secretion, particularly of the saliva and the urine. 
On the other hand, the sweat-glands increase in activity, and in nursing 
women it has been stated that the lacteal flow is unaffected. This stage 
sometimes lasts not more than two or three hours, but more commonly from 
twelve to twenty-four. There are instances in which the patient dies 
before purging begins — the so-called cholera sicca. 

(c) Reaction Stage. — When the patient survives the collapse, the cyano- 
sis gradually disappears, the warmth returns to the skin, which may have 
for a time a mottled color or present a definite erythematous rash. The 
heart's action becomes stronger, the urine increases in quantity, the irrita- 
bility of the stomach disappears, the stools are at longer intervals, and there 
is no abdominal pain. In the reaction the temperature may not rise above 
normal. Not infrequently this favorable condition is interrupted by a recur- 
rence of severe diarrhoea and the patient is carried off in a relapse. Other 
cases pass into the condition of what lias been called cholera-typhoid, a 
state in which the patient is delirious, the pulse rapid and feeble, and (lie 



180 



SPECIFIC INFECTIOUS DISEASES. 



tongue dry. Death finally occurs with coma. These symptoms have been 
attributed to uraemia. 

During epidemics attacks are found of all grades of severity. There 
are cases of diarrhoea with griping pains, liquid, copious stools, vomiting, 
and cramps, with slight collapse. To these the term cholerine has been 
applied. They resemble the milder cases of cholera nostras. At the oppo- 
site end of the series there are the instances of cholera sicca, in which 
death may occur in a few hours after the onset, without diarrhoea. There 
are also cases in which the patients are overwhelmed with the poison and 
die comatose, without the preliminary stage of collapse. 

Complications and Sequelae. — The typhoid condition has al- 
ready been referred to. The consecutive nephritis rarely induces dropsy. 
Diphtheritic colitis has been described. There is a special tendency to 
diphtheritic inflammation of the mucous membranes, particularly of the 
throat and genitals. Pneumonia and pleurisy may develop, and destruc- 
tive abscesses may occur in different parts. Suppurative parotitis is not 
very uncommon. In rare instances local gangrene may develop. A trouble- 
some symptom of convalescence is cramps in the muscles of the arms and 
legs. 

Diagnosis. — The only affection with which Asiatic cholera could be 
confounded is the cholera nostras, the severe choleraic diarrhoea which 
occurs during the summer months in temperate climates. The clinical 
picture of the two affections is identical. The extreme collapse, vomiting, 
and rice-water stools, the cramps, the cyanosed appearance, are all seen in 
the worst forms of cholera nostras. In enfeebled persons death may occur 
within twelve hours. It is of course extremely important to be able to diag- 
nose between the two affections. This can only be done by one thoroughly 
versed in bacteriological methods, and conversant with the diversified flora 
of the intestines. The comma bacillus is present in the dejections of a 
great majority of the cases and can be seen on cover-glass preparations. 
Though the eye of the expert may be able to differentiate between the 
bacillus of true cholera and that which occurs in cholera nostras, cultures 
should be made, from which alone positive results can be obtained. 

Attacks very similar to Asiatic cholera are produced in poisoning by 
arsenic, corrosive sublimate, and certain fungi; but a difficulty in diagnosis 
could scarcely arise. 

The prognosis is always uncertain, as the mortality ranges in different 
epidemics from 30 to 80 per cent. Intemperance, debility, and old age 
are unfavorable conditions. The more rapidly the collapse sets in, the 
greater is the danger, and as Andral truly says of the malignant form, " It 
begins where other diseases end — in death." Cases with marked cyanosis 
and very low temperature rarely recover. 

Prophylaxis. — Preventive measures are all-important, and isolation 
of the sick and thorough disinfection have effectually prevented the dis- 
ease entering England or the United States since 1873. On several occa- 
sions since that date cholera has been brought to various ports in America, 
but has been checked at quarantine. During epidemics the greatest care 
should be exercised in the disinfection of the stools and linen of the pa- 



CHOLERA ASIATICA. 



181 



tients. When an epidemic prevails, persons should be warned not to drink 
water unless previously boiled. Errors in diet should be avoided. As the 
disease is not more contagious than typhoid fever, the chance of a person 
passing safely through an epidemic depends very much upon how far he 
is able to carry out thoroughly prophylactic measures. Digestive disturb- 
ances are to be treated promptly, and particularly the diarrhoea, which so 
often is a preliminary symptom. For this, opium and acetate of lead and 
large doses of bismuth should be given. 

Medicinal Treatment. — During the initial stage, when the diar- 
rhoea is not excessive but the abdominal pain is marked, opium is the most 
efficient remedy, and it should be given hypodermically as morphia. It is 
advisable to give at once a full dose, which may be repeated on the return 
of the pain. It is best not to attempt to give remedies by the mouth, as 
they disturb the stomach. Ice should be given, and brandy or hot coffee. 
In the collapse stage, writers speak strongly against the use of opium. Un- 
doubtedly it must be given with caution, but, judging from its effects in 
cholera nostras, I should say that collapse per se was not a contra-indica- 
tion. The patient may be allowed to drink freely. For the vomiting, which 
^is very difficult to check, cocaine may be tried, and lavage with hot water. 
Creasote, hydrocyanic acid, and creolin have been found useless. Eumpf 
advises calomel (gr. -J) every two hours. 

External applications of heat should be made and a hot bath may be 
tried. Warm applications to the abdomen are very grateful. Hypodermic 
injections of ether will be found serviceable. 

Irrigation of the bowel — enteroclysis — with warm water and soap, or 
tannic acid (2 per cent), should be used. With a long, soft-rubber tube, 
as much as 3 or 4 litres may be slowly injected. Not only is the colon 
cleansed, but the small bowel may also be reached, as shown by the fact 
that the tannic-acicl solutions have been vomited. 

Owing to the profuse serous discharges the blood becomes concentrated, 
and absorption takes place rapidly from the lymph-spaces. To meet this, 
intravenous injections were introduced by Latta, of Leith, in the epidemic 
of 1832. My preceptor, Bovell, first practised the intravenous injections 
of milk in Toronto, in the epidemic of 1854. A litre of salt solution at 107° 
may be injected, and repeated in a few hours if no reaction follows. Less 
risky and equally efficacious is the subcutaneous injection of a saline solu- 
tion. For this, common salt should be used in the proportion of about four 
grammes to the liter. With rubber tubing, a cannula from an aspirator, or 
even with a hypodermic needle, the warm solution may be allowed to run 
by pressure beneath the skin. It is rapidly absorbed, and the process may 
be continued until the pulse shows some sign of improvement. This is 
really a valuable method, thoroughly physiological, and should be tried 
in all severe cases. 

In the stage of reaction special pains should be taken to regulate the 
diet and to guard against recurrences of the severe diarrhoea. 



182 



SPECIFIC INFECTIOUS DISEASES. 



XXI. YELLOW FEVER. 

Definition. — A fever of tropical and subtropical countries, character- 
ized by a toxaemia of varying intensity, with jaundice, albuminuria, and a 
marked tendency to haemorrhage, especially from the stomach, causing the 
" black vomit." The specific organism has not yet been found, but the dis- 
ease is capable of being transmitted through the bite of mosquitoes. 

Etiology. — The disease prevails endemically in the West Indies and 
in certain sections of the Spanish Main. From these regions it occasionally 
extends and, under suitable conditions, prevails epidemically in the South- 
ern States. ~Row and then it is brought to the large seaports of the Atlantic 
coast. Formerly it occurred extensively in the United States. In the 
latter part of the last century and the beginning of this, frightful epi- 
demics prevailed in Philadelphia and other Northern cities. The epidemic 
of 1793, in Philadelphia, so graphically described by Matthew Carey, was 
the most serious that has ever visited any city of the Middle States. The 
mortality, as given by Carey, during the months of August, September, 
October, and November, was 4,041, of whom 3,435 died in the months of 
September and October. The population of the city at the time was only 
40,000. Epidemics occurred in the United States in 1797, 1798, 1799, and 
in 1802, when the disease prevailed slightly in Boston and extensively in 
Baltimore. In 1803 and 1805 it again appeared; then for many years the 
outbreaks were slight and localized. In 1853 the disease raged throughout 
the Southern States. There were moderately severe epidemics in 1867, 
1873, and 1878; and still milder ones in 1897, 1898, and 1899. In July, 
1899, a local outbreak occurred in the Soldiers' Home, at Hampton, Va. 
There were 45 cases, with 13 deaths. In Cuba the disease prevails during 
the summer season, and in Havana last year (1900) there was an unusually 
severe outbreak. In Europe it has occasionally gained a foothold, but there 
have been no widespread epidemics except in the Spanish ports. The dis- 
ease exists on the west coast of Africa. It is sometimes carried to ports in 
Great Britain and France, but it has never extended into those countries. 
The history of the disease and its general symptomatology are exhaustively 
treated of in the classical works of Rene La Roche and Berenger-Feraud. 

Guiteras recognizes three areas of infection: (1) The focal zone in which 
the disease is never absent, including Havana, Yera Cruz, Rio, and other 
Spanish- American ports. (2) The perifocal zone or regions of periodic epi- 
demics, including the ports of the tropical Atlantic in America and Africa. 
(3) The zone of accidental epidemics, between the parallels of 45° north 
and 35° south latitude. 

Conditions favoring the Development of Epidemics. — Yellow fever is a 
disease of the sea-coast, and rarely prevails in regions with an elevation 
above 1,000 feet. Its ravages are most serious in cities, particularly when 
the sanitary conditions are unfavorable. It is always most severe in the 
badly drained, unhealthy portions of a city, where the population is crowded 
together in ill-ventilated, dark houses. The disease prevails during the hot 
season. Humidity and heat seem to be the proper coefficients for the pres- 
ervation of the poison. 



YELLOW FEVER. 



183 



The epidemics in the United States have always been in the summer and 
autumn months, disappearing rapidly with the onset of cold weather. 

Mode of Transmission. — (a) By Direct Contagion. — There seems 
to be very little risk in nursing the disease. In Cuba very few of the 
nurses or doctors in attendance upon yellow-fever patients have been 
affected. Walter Eeed tells me that, so far as he knows, not one nurse or 
doctor contracted the disease by nursing the sick in Cuba, unless the nurs- 
ing was done in a house known to be infected. In one hospital in the 
suburbs of Havana five non-immune female nurses nursed more than one 
hundred yellow-fever cases during 1900 without contracting the disease. 

(6) By Fomites. — No belief is more strong among the laity than that 
the disease is transmitted by infected clothing, and quarantine efforts are 
chiefly directed to the disinfection of fomites of all sorts shipped from 
infected ports. A remarkable series of experiments have been reported by 
the Yellow Fever Commission of the United States Army, consisting of 
Drs. Walter Reed, Carroll, Lazear, and Agramonte, which go far to show 
that the disease can not be conveyed in this way. At Camp Lazear, Cuba, 
a frame house was so constructed as to shut out the sunlight and fresh air, 
and the vestibule was thoroughly screened. The average temperature for 
sixty-three days was kept about 76° F. Boxes filled with sheets, pillow- 
slips, blankets, etc., contaminated by contact with cases of yellow fever 
and the discharges, were placed in the house. Dr. E. P. Cooke and two 
privates of the hospital corps, all non-immunes, entered this building and 
unpacked the boxes, and for a period of twenty days occupied the room, 
each morning packing the infected articles in the boxes, and at night un- 
packing them. In their experiments with the fomites, in all seven non- 
immune subjects during the period of sixty-three days lived in contact with 
the fomites and remained perfectly well. These experiments, conducted 
in the most rigid and scientific manner, go far to discredit the belief in the 
transmission of the disease by fomites. 

(c) Transmission by Mosquitoes. — Carlos Finlay, of Havana, in 1881 
suggested that the disease was transmitted by mosquitoes. Stimulated by 
the work of Eoss on malaria, the American Commission above-named has 
demonstrated conclusively that yellow fever may be transferred by the 
mosquito, culex fasciatus (Fabricius), previously fed on the blood of infected 
persons. Non-immunes were kept under the most rigid quarantine for a 
period outside the endemic area, and then exposed in a specially constructed 
house to the bites of mosquitoes that had previously bitten cases of yellow 
fever. The experiment fulfilled the most exacting conditions of scientific 
accuracy, and forms a model of its kind. 

The Commission showed also that in non-immunes the disease could 
be ]) rod need by either the subcutaneous or the intravenous injection of 
blood taken from patients suffering with the disease. 
* An interval of about twelve days or more after contamination appears 
to be necessary before the mosquito is capable of introducing the infection. 
The bite at an early period after contamination does not confer immunity 
against a subsequent attack. The period of incubation in 13 cases of ex- 
perimental yellow fever varied from forty-one hours to five days and seven- 
teen hours. 



18.4 



SPECIFIC INFECTIOUS DISEASES. 



We must bear testimony to the heroism of the young soldiers who vol- 
untarily, without any compensation and purely in the interests of human- 
ity, submitted to the experiments, and also to the zeal and devotion with 
which members of our profession have, at the greatest possible risks, 
attempted to solve the riddle of this most serious disease. The death from 
the disease of Dr. Lazear, of the American Commission, and of Dr. Myers, 
of the Liverpool Commission, adds two more names to the already long 
roll of the martyrs of science. 

As Eeed points out, the mosquito theory fits in with well-recognized 
facts in connection with the epidemics. After the importation of a case 
into an uninfected region, a definite period of time elapses, rarely less than 
two weeks, before a second case occurs. Like malaria, the disease prevails 
most during the mosquito season, and disappears with the appearance of 
frost. Probably, too, as in very malarious districts, the disease is kept up 
by its prevalence in a very mild form among children. As Guiteras re- 
marks, " the foci of endemicity are essentially maintained by the Creole 
infant population, which is subject to the disease in a very mild form." In 
all probability the immunity which is acquired by prolonged residence in 
a locality in which the disease is endemic is due to the occurrence of very 
slight attacks. 

It has been shown that one attack does not always confer immunity. 
Eosenau reports two attacks within a period of eight years, and Libby two 
attacks within a period of two years. 

The Specific Germ. — The transmission by the mosquito makes it very ' 
probable, reasoning from analogy, that the germ of the disease is a proto- 
zoon; but of this there is no evidence as yet. There are three views at 
present held: 

L Bacillus icteroides of Sanarelli, which he claims is found in more 
than half of the cases, and produces what he calls an amaril poison with 
three special properties — emetic, hemorrhagic, and steatogenic. The 
claims of Sanarelli have been disputed by Novy, and also by the Yellow 
Fever Commission of the United States Army, which in 1900, in 18 
cases of typical yellow fever, failed to find bacillus icteroides in the 
blood in a single case, and the same negative results were obtained in 
11 autopsies.' 

2. From what I can gather, a majority of those whose bacteriological 
training makes them fit judges, incline strongly to the belief that the 
specific organism of the disease has not yet been discovered. 

3. Quite recently Durham and Myers, of the Liverpool Yellow Fever 
Commission, have found a small, fine influenza-like bacillus in scanty num- 
bers in organs of perfectly fresh cadavers. They confirm Sternberg's state- 
ment of the extraordinary numbers of similar small bacilli in mucus of 
evacuations and of intestinal contents. It did not grow upon ordinary 
media. 

Morbid Anatomy. — The skin is more or less jaundiced, even though 
the patient did not appear yellow before death. Cutaneous haemorrhages 
may be present. No specific or distinctive internal lesions have been found. 
The blood-serum may contain haemoglobin, owing to destruction of the 



YELLOW FEVER. 



185 



red cells, just as in pernicious malaria. The heart sometimes, not invaria- 
bly, shows fatty change; the stomach presents more or less hyperemia of 
the mucosa with catarrhal swelling. It contains the material which, ejected 
during life, is known as the black vomit. The essential ingredient in this is 
transformed blood-pigment. There is no proof that this black material 
depends upon the growth of a micro-organism. There is often general 
glandular enlargement; the cervical axillary and mesenteric groups are 
most involved. The liver is usually of a pale yellow or brownish-yellow 
color, and the cells are in various stages of fatty degeneration. From the 
date of Louis' observations at Gibraltar in 1828, the appearances of this 
organ have been very carefully studied, and some have thought the changes 
in it to be characteristic. Councilman has described remarkable appear- 
ances in the liver-cells which he believes are distinctive and peculiar. Fatty 
degeneration and regions of necrosis are present in all cases. The kidneys 
always show traces of diffuse nephritis. The epithelium of the convoluted 
tubules is swollen and very granular; there may also be necrotic changes. 
In both liver and kidneys bacteria of various sorts have been described. 

Symptoms. — The incubation is usually three or four days; in 13 
experimental cases it ranged from forty-one hours to five days seventeen 
hours. The onset is sudden, as a rule, without premonitory symptoms, and 
in the early hours of the morning. Chilly feelings are common, and are 
usually associated with headache and very severe pains in the back and 
limbs. The fever rises rapidly and the skin feels very hot and dry. The 
tongue is furred, but moist; the throat sore. Nausea and vomiting are not 
constant, and become more intense on the second or third day. The 
bowels are usually constipated. The following, in detail, are the more 
important characteristics: 

Fades. — Even as early as the first morning the patient may present a 
very characteristic facies, according to Guiteras, one of the three distin- 
guishing features of the disease. The following description is taken from 
him: The face is decidedly flushed, more so than in any other acute infec- 
tious disease at such an early period. The eyes are injected, the color is 
a bright red, and there may be a slight tumefaction of the eyelids and of 
the lips. Even at this early date there is to be noticed in connection with 
the injection of the superficial capillaries of the face and conjunctive an 
element of icterus, and " the early manifestation of jaundice is undoubtedly 
the most characteristic feature of the facies of yellow fever." It has to be 
looked for very carefully. 

The Fever. — On the morning of the first day the temperature may vary 
between 100° and 106°, usually between 102° and 103°. During the even- 
ing of the first day and the morning of the second day the temperature 
keeps about the same. There is a slight diurnal variation on the second 
and third day. In very mild cases the fever may fall on the evening of the 
second or on the morning of the third day, or in abortive cases or in unde- 
veloped cases in children even at the end of twenty-four hours. In eases 
that are to terminate favorably the defervescence takes place by lysis during 
a period of two or three days. The remission or stage of calm, as it has been 
called, is succeeded by a febrile reaction or secondary fever, which lasts one. 



186 



SPECIFIC INFECTIOUS DISEASES. 



two, or three days, and in favorable cases falls by a short lysis. On the 
other hand, in fatal cases the temperature is continuous, becomes higher 
than in the initial fever, and death follows shortly. 

The Pulse. — On the first day the pulse is rarely more than 100 or 110. 
On the second or third day, while the fever still keeps up, the pulse begins 
to fall, and may have become slower by as much as 20 beats while the tem- 
perature has risen 1.5° or 2°. On the evening of the third day there may be 
a temperature range of 103° and a pulse of only 75, or "a temperature 
between 103° and 104° with a pulse running from 70 to 80." This impor- 
tant diagnostic feature was first described by Faget, of New Orleans. Dur- 
ing the defervescence the pulse may become still slower, down to 50, 48, or 
45, or even as low as 30. A slow pulse with the defervescence is not the 
special circulatory feature of the disease, but the slowing of the pulse with 
a steady or even rising temperature. 

Albuminuria. — This, regarded by Guiteras as the third characteristic 
symptom of the disease, occurs as early as the evening of the third day. He 
says very truly that it is very rare so early in other fevers except those of an 
unusually severe type. " Even in the mild cases that do not go to bed — 
cases of tf walking yellow fever 9 — on the second, third, or fourth day of 
the disease albuminuria will show itself." It may be quite transient. In 
the severer cases the amount of albumin is very large, and there may be 
numerous tube-casts and all the signs of an intense acute nephritis; or 
complete suppression of the urine may 'supervene, and death may occur in 
ursemic convulsions or coma within twenty-four or thirty-six hours. Gui- 
teras insists that the evening urine should be specially examined. He 
states that the presence of albumin on the first day and its persistence on 
the second indicate a severe case. With the secondary rise in temperature 
the jaundice becomes more intense. 

Gastric Features. — " Black Vomit." — Irritability of the stomach is 
present from the very outset, and the vomited matter consists of the con- 
tents of the stomach, and subsequently of mucus and a grayish fluid. In 
the third stage of the disease the vomiting becomes more pronounced and 
in the severe cases is characterized by the presence of blood. It may be 
copious and forcible, producing much pain in the abdomen and along the 
gullet. There is nothing specific in the " black vomit " of yellow fever. 
It consists of altered blood. " Black vomit " is not necessarily a fatal 
symptom, though it occurs only in the severer forms of the disease. Other 
hemorrhagic features may be present — petechia? on the skin and bleeding 
from the gums or from other mucous membranes. The bowels are usually 
constipated, the stools not clay-colored, except late in the disease. They 
are sometimes tarry from the presence of altered blood. 

Mental Features. — In very severe cases the onset may be with active 
delirium. " As a rule, in a majority of cases, even when there is black 
vomit, there is a peculiar alertness; the patient watches everything going 
on about him with a peculiar intensity and liveliness. This may be due 
in part to the terror the disease inspires " (Guiteras). The first signs of 
mental cloudiness may be due to the uraemic coma. 

Relapses occasionally occur. Among the varieties of the disease it is 



YELLOW FEVER. 



187 



important to recognize the mild cases. These are characterized by slight 
fever, continuing for one or two days, and succeeded by a rapid convales- 
cence. Such cases would not be recognized as yellow fever in the absence 
of a prevailing epidemic. Cases of greater severity have high fever and 
the features of the disease are well marked — vomiting, extreme prostra- 
tion, and haemorrhages. And lastly, there are malignant cases in which 
the patient is overwhelmed by the intensity of the fever, and death takes 
place in two or three days. 

In severe cases convalescence may be complicated by the occurrence of 
parotitis, abscesses in various parts of the body, and diarrhoea. An attack 
confers an immunity which persists, as a rule, through life. 

Diagnosis. — (a) From Dengue. — The difficulty in the differential 
diagnosis of these two diseases lies in their frequent coexistence, as during 
the epidemic of 1897 in parts of the Southern States. During the autumn 
of 1897 the profession of Texas was divided on the question of the exist- 
ence of yellow fever in the State, some claiming that the disease was 
dengue, others, including Guiteras and West, that yellow fever also existed. 
If the suspicious cases were dengue, break-bone fever is a much more 
serious disease than writers state, and certain of the symptoms, particu- 
larly haemorrhages, occur in a larger proportion of cases than has been 
heretofore acknowledged. Of the other symptoms, too, one writer states 
that jaundice of mild grade was the rule from first to last. Albumin was 
not infrequently present in the urine, and the lack of correlation between 
the pulse and the temperature was so frequent as to be almost the rule. 
There was no case of black vomit. Dengue, as I have stated in the article 
on that disease, prevailed to a remarkable extent in the city of Galveston. 
On the other hand, if the cases examined by Guiteras and declared by him 
to be yellow fever were truly examples of that disease, there is the anoma- 
lous — indeed, unique — fact of an outbreak of yellow 'fever in a city which 
had not had the disease in epidemic form since 1867, and in which it did 
not assume epidemic proportions and did not increase the death-rate, which 
for the months of August, September, and October of 1897 was lower than 
for the corresponding three months in 1896 and 1895. After a review 
of the local literature on the question, I confess myself to be quite unable 
to decide upon the points at issue. I have dwelt upon this matter in order 
that practitioners may realize how difficult the diagnosis may be under 
certain circumstances. It is quite useless to emphasize in parallel columns 
the differential points between the two diseases. Doubtless in a majority 
of all the cases the three diagnostic points upon which Guiteras lays stress 
— the facies, the albuminuria, and the slowing of the pulse with mainte- 
nance or elevation of the fever — are sufficient for the diagnosis. He states, 
too, that jaundice, which does sometimes occur in dengue, rarely appears as 
early as the second or third day of the disease, and on ibis much stress 
should be laid. Haemorrhages are much less common in dengue, but thai 
they do occur has been recognized by authorities ever since the time of 
Rush. It is a pity that we can not be more positive on this all-important 
point, but when an expert like Dr. John Guiteras is in doubt it behooves 
the average practitioner to be humble. 
12 



188 



SPECIFIC INFECTIOUS DISEASES. 



(b) From Malarial Fever. — In the early stages of an epidemic cases are 
very apt to be mistaken for forms of malarial fever. In the Southern States 
the outbreaks have usually been in the late summer months, the very season 
in which the aestivo-autumnal irregular malarial fever prevails. Among 
the points to be specially noted are the absence of early jaundice in ma- 
larial fever. Even in the most intense types of infection the color of the 
skin is rarely changed within four or five days. To the experienced eye 
the facies would be of considerable help if the case was seen from the 
outset. Albumin is rarely present in the urine so early as the second day 
in a malarial infection. Other important points are the marked swelling 
of the spleen in malaria, while in pure yellow fever it is not enlarged. 
Haemorrhages, and particularly the black vomit, epistaxis, and bleeding 
gums are very rare in malarial infection. In the so-called hemorrhagic 
malarial fever the patient has usually had previous attacks of malaria. 
Hematuria is a prominent feature, while in yellow fever it is by no means 
frequent. A special point of greater importance, perhaps, than any of 
these general symptomatic features is the careful examination of the blood 
for malarial parasites. The forms to be looked for are the small, ring- 
shaped organisms of the aestivo-autumnal infections. As a rule, their 
presence is readily determined by any one familiar with their general 
characters. They are, however, of all forms the most difficult to recog- 
nize, and, while they may be very abundant, there are cases in which the 
organisms are extremely scanty in the peripheral circulation. The work 
of the army surgeons in Cuba shows that in a large proportion of cases there 
is not much difficulty in recognizing the sestivo-autumnal fever from 
yellow fever. 

Prognosis. — In its graver forms, yellow fever is one of the most 
fatal of epidemic diseases. The mortality has ranged, in various epidemics, 
from 15 to 85 per cent. In heavy drinkers and those who have been ex- 
posed to hardships the death-rate is much higher than among the better 
classes. In the epidemic of 1878, in New Orleans, while the mortality in 
hospitals was over 50 per cent of the white and 21 per cent of the colored 
patients, in private practice it was not more than 10 per cent among the 
white patients. The death-rate was very low in the epidemic of 1897. 
Favorable symptoms are a low grade of fever, slight jaundice, absence of 
haemorrhages, and a free secretion of urine. If the temperature rise above 
103° or 104° during the first two days, the outlook is serious. Black vomit 
is not an invariably fatal s} 7 mptom. Cases with suppression of urine, de- 
lirium, coma, and convulsions rarely recover. 

Prophylaxis. — It is scarcely likely that quarantine measures will be 
abandoned before full confirmation of the work of the United States Yellow 
Fever Commission; but meanwhile every means should be taken to prevent 
the spread of the disease through infected mosquitoes. There are three 
important measures: (1) the protection of the sick from the bites of mosqui- 
toes; (2) the screening of houses, the use of mosquito nets, and the destruc- 
tion of the insects in the house; (3) measures such as already referred to 
under malaria, which diminish the possibility of the mosquito breeding in 
the neighborhood of dwellings. New-comers should be particularly careful 



THE PLAGUE. 



189 



in infected regions, and medical officers in charge of camps should exercise 
the most scrupulous care to prevent the spread of infection through 
mosquitoes. 

Treatment. — Careful nursing and a symptomatic plan of treatment 
probably give the best results. The patient should be removed at once 
from the infected house. Care should be taken to prevent chilling of the 
skin, and sweating should be promoted. Bleeding has long since been 
abandoned. An early purge, followed by phenacetin to relieve the back- 
ache, is recommended by Geddings. Of special remedies quinine is 'warmly 
recommended, and, when haemorrhage sets in, the perchloride of iron. 
Digitalis, aconite, and jaborandi have been employed. Sternberg advises 
the following mixture: Bicarbonate of soda, 150 grains; bichloride of mer- 
cury, -J grain; pure water, 1 quart. Three tablespoonfuls every hour. This 
is given on the view that the specific agent is in the intestine, and that 
its growth may possibly be restrained by this antacid and antiseptic mix- 
ture. The fever is best treated by hydrotherapy. There are several reports 
of the good effects of cold baths, sponging, and the application of ice-cold 
water to the head and the extremities in this disease. Vomiting is a very 
difficult symptom to control. Ice in small quantities is probably the best 
remedy. Cocaine may be tried in doses of J-J gr. every hour or two (Ged- 
dings). 

We have no drug which can be depended upon to check the haem- 
orrhages. Ergot and acetate of lead and opium are recommended. The 
ursemic symptoms are best treated by the hot bath. Stimulants should be 
given freely during the second stage, when the heart's action becomes 
feeble and there is a tendency to collapse. The patient should be carefully 
feci; but when the vomiting is incessant it is best not to irritate the stom- 
ach, but to give nutritive enemata until the gastric irritation is allayed. 
Washing out the lower bowel is very advantageous, and in the cases with 
extreme toxaemia the subcutaneous or intravenous injection of saline solu- 
tion may be tried. 

The serum treatment introduced by Sanarelli does not appear to have 
come into general use. 



XXII. THE PLAGUE. 

Definition. — A specific, infectious disease of extraordinary virulence 
and very rapid course, caused by bacillus pestis, characterized by in- 
flammation of the lymphatic glands (buboes), carbuncles, and often haem- 
orrhages. 

History and Geographical Distribution.— The disease was 
i robably not known to the classical Greek writers. The earliesl positive 
account dates from the second century of our era. The plague of Athens 
and the pestilence of the reign of Marcus Aurelius were apparently not this 
disease (Payne). From the great plague in the days of Justinian (sixth 
century) to the middle of the seventeenth century epidemics of varying 
severity occurred in Europe. Among the most disastrous was the famous 



190 



SPECIFIC INFECTIOUS DISEASES, 



" black death of the fourteenth century, which overran Europe and de- 
stroyed a fourth of the population. In the seventeenth century it raged 
virulently, and during the great plague of London, in 1665, about 70,000 
people died. During the eighteenth and nineteenth centuries the ravages 
of the disease lessened. 

The revival of the plague within the past ten years has aroused uni- 
versal interest. Since the outbreak at Hong-Kong, in 1891, the disease 
has appeared in many parts of the world. The most serious outbreak has 
been in India, particularly in the Presidency of Bombay. In the city of 
Bombay itself within nine months after the onset at least 20,000 people 
died of the disease. It continues to spread in India. In Africa outbreaks 
have occurred in Egypt, and lately at the Cape. In Europe cases have 
been carried to different ports on the Mediterranean, and there was a local 
outbreak at Oporto. After an absence of more than two hundred years, 
plague obtained a foothold in Great Britain, and in Glasgow there was a 
small epidemic in the autumn of 1900. A few cases have been carried 
also to other ports. In South America there have been a few cases at 
Brazilian ports. The disease reached quarantine in New York in Novem- 
ber, 1899. In San Francisco there has been a localized epidemic among 
the Chinese. In Australia the disease has jDrevailed in S}-dney and one 
or two other towns. 

A most encouraging circumstance is the fact, well illustrated in Glas- 
gow and San Francisco, that the disease is readily held in cheek by proper 
sanitary measures. 

Etiology. — The specific organism of the disease is a bacillus discov- 
ered by Kitasato and carefully studied by Yersin and others. It resembles 
somewhat the bacillus of chicken cholera, and grows in a perfectly char- 
acteristic manner. The bacillus pestis occurs in the blood and in the 
organs of the body, and has also been found in the dust and in the soil of 
houses in which the patients have lived. Flies and fleas die from the dis- 
ease, and may convey the infection. Bats, mice, and dogs are readily in- 
fected, and diseased animals will convey the plague to healthy ones. Prior 
to the onset of epidemics in man the disease has prevailed extensively 
among the rats. 

The disease prevails most frequently in hot seasons, though an out- 
break may occur during the coldest weather of winter. Persons of all ages 
are attacked. It spreads chiefly among the poorer classes, in the slums of 
the" great cities, and, in fact, wherever the hygienic conditions are most 
faulty. There is much in favor of the view that the plague is a soil disease, 
the virus of which, like that of anthrax and tetanus, resides permanently 
in the soil of the affected districts (see Payne in Allbutt's System). The 
method of spread was well recognized by De Foe: "No one in this whole 
nation ever received the sickness or infection but who received it in the 
ordinary way of infection from somebody, or the clothes, or touch, or 
stench of somebody that was infected before." 

While the virus of the plague may be communicated from one person 
to another through the air, the disease has not the extreme contagiousness 
of small-pox or of scarlet fever. It attaches itself particularly to houses 



THE PLAGUE. 



191 



and to the clothing and bedding. In the Bombay epidemic few attendants 
upon the sick — nurses and physicians — have been attacked, and a writer 
states that among the hundreds of British troops daily employed on cordon 
duty and search parties and in the disinfection of houses not a single case 
occurred. 

Clinical Forms. — Pestis Minor. — In this variety, also known as the 
ambulant, the patient has a few days of fever, with swelling of the glands 
of the groin, and possibly suppuration. He may not be ill enough to seek 
medical relief. These cases, often found at the beginning and end of an 
epidemic, are a very serious danger in a community, as the urine and faeces 
contain bacilli. 

Bubonic Plague. — This constitutes the common variety, 77.65 per cent 
of 11,600 cases of plague treated in the Arthur Eoad Hospital, Bombay 
(N. H. Choksy). The stage of invasion is characterized by headache, back- 
ache, stiffness of the limbs, a feeling of anxiety and restlessness, and great 
depression of spirits. There is a steady rise in the fever until the evening 
of the third or fourth day, when there is a drop of two or three 'degrees. 
There is then a secondary fever, as some writers describe it, in which the 
temperature reaches a still higher point. The tongue becomes brown, 
collapse symptoms are apt to supervene, and in very severe infections the 
patient may die at this stage. In at least two-thirds of all cases there are 
glandular swellings or buboes. An analysis of 9,500 cases of buboes gave 
more than 54 per cent with the glands of the groin affected. The swelling 
appears usually from the third to the fifth day. Kesolution may occur, 
or suppuration, or in rare cases gangrene. Suppuration is a favorable 
feature, as noted by De Foe in his graphic account of the London plague. 

Petechias very commonly show themselves, and may be very extensive. 
These have been called the " plague spots," or the " tokens of the disease," 
and gave to it in the middle ages the name of the Black Death. Haemor- 
rhages from the mucous membranes may also occur; in some epidemics 
haemoptysis has been especially frequent. 

Septicemic Plague. — In this form, which is the most rapid, the patient 
succumbs in three or four days with a virulent infection before the buboes 
appear. This form constituted 14.25 per cent of the 11,600 cases. Haem- 
orrhages are common. The bacilli can be obtained from the blood. 

Pneumonic Plague. — This remarkable variety presents the features of 
a pneumonia, and the sputum contains the bacilli in enormous numbers. 
It is even more fatal than the septicaemic type. The mortality in 514 
cases was 96.69 per cent. It is of short duration. The fever is high, the 
respirations rapid, the pneumonia is chiefly lobular, the sputa haemor- 
rhagic, and contain the bacilli in almost pure culture. 

In other varieties the chief manifestations may be in the skin and 
subcutaneous tissues, or in the intestines, causing diarrhoea and sometimes 
the features of typhoid fever. 

Prophylaxis. — Careful hygienic measures should be carried out, and 
all persons sick of the disease should be isolated. The most thorough 
disinfection of the evacuations should be carried out. The bodies of vic- 
tims should be cremated. Patients who have recovered should be kept in 



192 



SPECIFIC INFECTIOUS DISEASES. 



isolation for at least a month. A most important prophylactic measure 
relates to the destruction of rats, which are probably the chief agents in 
the distribution of the disease. As Dr. Ashburton Thompson remarks (Re- 
port on Plague at Sydney), " during an epidemic the only proceeding of 
much value is destruction of rats and of their nests, burrows, and habitual 
haunts, and those others which are calculated to prevent access of surviving 
rats to proximity with human beings — in other words, to expel them from 
occupied premises, and to keep them outside. ... On premises where in- 
digenous cases had occurred, moreover, the presence of freshly deceased 
rats was discovered quite often enough to support the general proposition 
that the danger of contracting plague stood in relation to the presence of 
rats in dwellings or inclosed premises. A general slaughter of rats would 
answer the purpose, if it could be carried out quickly and with tolerable 
completeness." 

Diagnosis. — At the early stage of an outbreak plague cases are easily 
overlooked, but if the suspicious cases are carefully studied by a compe- 
tent bacteriologist, there is no disease which can be more positively identi- 
fied. The San Francisco epidemic illustrates this. The nature of the cases 
was recognized by Kellog and by Kinyoun, but with an amazing stupidity 
(which was shared by not a few physicians, who should have known better) 
the Governor of the State refused to recognize the presence of plague, and 
the United States Government had to intervene and send a board of experts 
to settle the question. In the early Glasgow cases Dr. Colvin, while sus- 
pecting typhoid fever, saw that there was something unusual, and at once 
took precautionary measures. Probably, too, the association of four cases 
in one family made him suspicious. The limitation of the outbreak was 
due to the prompt and effective measures taken by Dr. A. K. Chalmers 
and his associates. The widespread prevalence of the disease makes it 
the imperative duty of the health authorities to have on hand, in con- 
nection with large ports, skilled men who can promptly make the bac- 
teriological diagnosis. There are dangers from the cultures in laboratories, 
as shown by the sad experiences of Vienna, but with proper precautions 
they may be reduced to a minimum. 

Treatment. — In a disease the mortality of which may reach as high 
as 80 or 90 per cent the question of treatment resolves itself into making 
the patient as comfortable as possible, and following out certain general 
principles such as guide us in the care of fever patients. Cantlie recom- 
mends purgation and stimulation from the outset, and the use of morphia 
for the pain. The local treatment of the buboes is important. Ice may be 
applied to them, and good results apparently follow the injection of the 
bichloride of mercury. The pyrexia of the disease is best treated by 
systematic hydrotherapy. Antipyrin and depressing drugs should be 
avoided. 

Preventive Inoculation. — Haffkine uses sterilized bouillon cultures of 
the bacillus, which appear to confer immunity lasting for a month or 
more. The reports on the whole are favorable. Yersin has prepared an 
antitoxic serum, which has been used extensively in the East, sometimes 
with favorable results. Roux has also prepared a serum, which is on the 



DYSENTERY. 



193 



market, and which is used for immunizing as for a therapeutic agent. 
Lustig's serum has been used extensively in India, and there are reports 
from Bombay which indicate that it has a distinctly favorable 'influence 
on the course of the disease. 

XXIII. DYSENTERY. 

Definition. — A clinical term embracing several varieties of intestinal 
flux — the acute forms characterized by pain, frequent passages of blood 
and mucus, the more chronic by diarrhoea alternating with constipation, 
and a tendency to recurrence. Anatomically there is inflammation, and 
in the chronic cases ulceration, of the large bowel. 

General Etiology. — Owing to improved sanitation, the diseases de- 
scribed under dysentery have become less frequent. In temperate climates 
sporadic cases occur from time to time, and at intervals epidemics prevail, 
particularly in overcrowded institutions. The statistics of general hos- 
pitals for the past twenty years show a decided decrease in the number 
of cases admitted. Eecords of widespread epidemics have been collected 
by Woodward. The most serious was that which prevailed from 1817 to 
1856. In Great Britain and Ireland epidemics of the disease have become 
less frequent. In institutions, particularly in overcrowded asylums, dysen- 
tery is very common, and this form has been made the subject of a valuable 
report by Mott and Durham. In the tropics " dysentery is a destructive 
giant compared to which strong drink is a mere phantom " (Macgregor). 
Dysentery is one of the great camp diseases, and it has been more destruc- 
tive to armies than powder and shot. In the Federal service during the 
civil war, according to Woodward,* there were 259,071 cases of acute 
and 28,451 cases of chronic, dysentery. The last report (1900) of Surgeon- 
General Sternberg shows that the disease has prevailed in Porto Eico, the 
Philippines, and to a less extent in Cuba. In the South African campaign 
dysentery has prevailed widely. 

A careful study is needed of the acute dysenteries of temperate regions, 
more particularly of the outbreaks which occur from time to time. Pro- 
visionally the following forms may be described: 

Acute Specific Dysentery. — For many years a very fatal form of 
dysentery has prevailed in Japan, particularly in the summer and autumn 
months, having a mortality of from 26 to 27 per cent; in 1899 there were 
125,989 cases, with 26,709 deaths (Eldridge). A Japanese observer, Shiga, 
found in connection with it a bacillus with special characters. Flexner 
and Barker, of the Johns Hopkins Commission for the Study of Tropical 
Diseases, found in the dysentery in the Philippine Islands an iclont ic-al 
organism, and it has been made the subject of very careful study by 
Flexner, and also by R. P. Strong, Musgrave, and Craig, of the United 
Slates army. It has also been found in cases of dysentery from Porto Kieo. 



* Medical and Surgical History of the War of the Rebellion, Medical, vol. ii. The 
most exhaustive treatise extant on intestinal fluxes— an enduring monument to the indus- 
try and ability of the author. 



194 



SPECIFIC INFECTIOUS DISEASES. 



The organism appears to be constantly present in the acute dysentery of 
the tropics. It is pathogenic to animals, and Flexner has produced in 
rabbits a typical acute colitis by subcutaneous inoculation of cultures. The 
organism agglutinates with the blood-serum of cases of acute dysentery. 

B. dysenteries. — Bacillus of average length of B. typhosus. Grows 
readily upon all culture media. Colonies upon gelatin, when fully devel- 
oped, show a grape-leaf appearance. There is no liquefaction of gelatin. 
Sugars are not fermented and milk is not coagulated. In litmus milk 
there is at first a small amount of acid production which is followed by 
alkalinization. The bacillus when first isolated is slightly motile, but 
quickly loses its motility in artificial cultivations. Flagella have not been 
demonstrated. Feeding animals on the bacilli, unless the intestinal tract 
is previously irritated with chemicals, has no effect. Feeding after irrita- 
tion sets up colitis in cats and dogs. Intraperitoneal and subcutaneous 
injections into mice, rabbits, and guinea-pigs are lethal. In the rabbit, 
subcutaneous injections have, in some instances, given rise to extensive 
pseudo-membranous inflammations of the csecum (Flexner). 

In Manila, according to the figures by Strong and Musgrave, of 1,328 
cases 712 were of the acute specific variety, 55 suspected specific cases, 
and 561 of amoebic dysentery. Kruse, in an outbreak at Laar in Germany, 
in which 300 persons were attacked, has isolated an identical bacillus. In 
the epidemic in the Lancaster County Asylum, so fully reported by Gem- 
mel, Goodliffe found an organism which evidently has close affinities with 
Shiga's bacillus. Outbreaks in temperate regions should be most carefully 
studied, as it seems probable that the disease is identical with the acute 
specific dysentery of the tropics. 

Clinical Features. — It ocurs sporadically, and at intervals prevails in 
epidemic form. For many years now it has recurred in the autumn in 
Japan with great severity. In the Philippines it is widely spread over 
the islands, and appears chiefly toward the end of the rainy season. The 
precise channel of infection is not known, but it is possibly through the 
drinking-water. According to Strong and Musgrave, the period of incu- 
bation is not more than forty-eight hours. 

The onset, which is usually sudden, is characterized by slight fever, 
pain in the abdomen, and frequent stools. At first mucus is passed, but 
within twenty-four hours blood appears with it, or there is pure blood. 
There is a constant desire to go to stool, with great straining and tenes- 
mus; every hour or half hour there may be a small amount of blood and 
mucus passed. The temperature rises and may reach 103° or 101°. The 
pulse increases in frequency, and in the severer cases becomes very small. 
The tongue is coated with a white fur, and there is excessive thirst. In 
the very acute cases the patient becomes seriously ill within forty-eight 
hours, the movements increase in frequency, the pain is of great intensity, 
the patient becomes delirious, and death may occur on the third or fourth 
day. In cases of moderate severity the urgency of the symptoms abates, 
the stools lessen, the temperature falls, and within two or three weeks 
the patient is convalescent. The mortality in the severe forms is very 
high, and the Japanese records show how fatal the disease is. There is a 



DYSENTERY. 



195 



subacute form which lasts for many weeks or months. The patients be- 
come greatly emaciated, having from three to five stools in the twenty- 
four hours. In this form, too, the bacillus dysenteriae is found, and it 
agglutinates readily with the blood serum. Strong and Musgrave have 
found it as early as the third day. Amoebae are not found in the stools. 

Morbid Anatomy. — In the acute cases, when death has occurred on 
the fourth to the seventh day, the mucous membrane of the large intes- 
tine is swollen, of a deep-red color, and presents elevated, coarse corruga- 
tions and folds. In addition to the intense hyperaemia there are spots of 
haemorrhage scattered through the swollen mucosa. Over the surface 
there is usually a superficial necrotic layer, which can be brushed off lightly 
with the finger. This may be in patches, or uniform over large areas. 
There is no ulceration, only the superficial, general necrosis of the mucosa. 
The solitary follicles are swollen and red, but the prominence is obscured 
in the involvement of the entire mucosa. In cases of great intensity the 
entire coats of the colon may be stiff and thick, and the mucous membrane 
enormously increased in thickness, grayish black in color, extensively 
necrotic, and, in places, gangrenous. The serous surface is often deeply 
injected. The ileum is, in many cases, involved, having a deeply haemor- 
rhagic mucosa, with a superficial necrosis. In the subacute cases there 
is not the same great thickening of the intestinal wall, the solitary fol- 
licles are more swollen, there is less necrosis, and, while there are no 
ulcers, there are superficial erosions. 

Amoebic Dysentery. — This is a widely prevalent form, which has 
been described in Egypt, in India, and in the tropics. It is the commonest 
variety throughout the United States, and is exceedingly common in the 
Philippine Islands. It is endemic, the cases sometimes increasing to such 
an extent as to form an epidemic. Sporadic instances apparently occur 
in all temperate regions. 

Amoeba Dysenterice. — The organism was first described by Lambl in 
1859, and subsequently by Losh. Kartulis found them in the stools of 
the endemic dysentery in Egypt, and in the liver abscesses. In 1890 
I found them in a case of dysentery with abscess of the liver originating in 
Panama. Subsequently from my wards a series of cases was described 
by Councilman and Lafleur. Since then numbers of observations have 
been made by Dock in this country, by Quincke and Roos in Germany, and 
by many others. The little flakes of mucus or pus in the stools should be 
selected for examination or the mucus obtained by passing a soft-rubber 
catheter. Students must learn to distinguish from amoeba the swollen, 
altered epithelial cells, which are round, with granular protoplasm. 

Amoeba dysenteriae are from fifteen to twenty //. in diameter, and con- 
sist of a clear outer zone (ectosarc), and a granular inner zone (endosarc), 
and contain a nucleus and one or two vacuoles. Tin 1 movements are 
vi tv similar to those of the ordinary amoeba, consisting 0 f slight 
protrusions of the protoplasm. They vary a good deal, and usually may 
be intensified by having the slide heated. Not infrequently the amoeba 
contain red blood-corpuscles which they have included. In the tissues they 
are very readily recognized by suitable stains. They may be in enormous 



196 



SPECIFIC INFECTIOUS DISEASES. 



numbers, and sometimes the field of the microscope is completely occupied 
by them. In the pns of a liver abscess they may be very abundant, though 
in large, long-standing abscesses they may not be found until after a few 
days, when the pus begins to discharge from the wall of the abscess cavity. 
In the sputum in the cases of pulmono-hepatic abscess they are readily 
recognized. There are probably different varieties of amcebse. They have 
been found in the stools of perfectly healthy persons. Quincke and Koos 
recognize three varieties, and Strong describes two distinct forms in 
Manila, only one of which is pathogenic. 

The relative frequency of this form of dysentery in the tropics is well 
illustrated by the experience of the United States army in Manila. As 
already stated, the figures given by Strong are of 1,328 cases; 561 were of 
the amoebic variety. 

In this region the amoebic dysentery is the common variety, and the 
cases of acute and chronic dysentery admitted to my wards during the past 
twelve years have been almost exclusively of this form. 

Morbid Anatomy. — The lesions are found in the large intestine, some- 
times in the lower portion of the ileum. Abscess of the liver is a common 
sequence. Perforation into the right lung is not infrequent. 

Intestines. — The lesions consist of ulceration, produced by preceding 
infiltration, general or local, of the submucosa, due to an cedematous con- 
dition and to multiplication of the fixed cells of the tissue. In the earliest 
stage these local infiltrations appear as hemispherical elevations above the 
general level of the mucosa. The mucous membrane over these soon be- 
comes necrotic and is cast off, exposing the infiltrated submucous tissue as 
a grayish-yellow gelatinous mass, which at first forms the floor of the 
ulcer, but is subsequently cast off as a slough. 

The individual ulcers are round, oval, or irregular, with infiltrated, 
undermined edges. The visible aperture is often small compared to the 
loss of tissue beneath it, the ulcers undermining the mucosa, coalescing, 
and forming sinuous tracts bridged over by apparently normal mucous 
membrane. According to the stage at which the lesions are observed, the 
floor of the ulcer may be formed by the submucous, the muscular, or the 
serous coat of the intestine. The ulceration may affect the whole or some 
portion only of the large intestine, particularly the caecum, the hepatic 
and sigmoid flexures, and the rectum. In severe cases the whole of the 
intestine is much thickened and riddled with ulcers, with only here and 
there islands of intact mucous membrane. 

The disease advances by progressive infiltration of the connective-tissue 
layers of the intestine, which produces necrosis of the overlying structures. 
Thus, in severe cases there may be in different parts of the bowel slough- 
ing en masse of the mucosa or of the muscularis, and the same process is 
observed, but not so conspicuously, in the less severe forms. 

In some cases a secondary diphtheritic inflammation complicates the 
original lesions. 

Healing takes place by the gradual formation of fibrous tissue in the 
floor and at the edges of the ulcers, which may ultimately result in partial 
and irregular strictures of the bowel. 



DYSENTERY. 



197 



Microscopical examination shows a notable absence of the products of 
purulent inflammation. In the infiltrated tissues polynuclear leucocytes 
are seldom found, and never constitute purulent collections. On the other 
hand, there is proliferation of the fixed connective-tissue cells. Amoebae 
are found more or less abundantly in the tissues at the base of and around 
the ulcers, in the lymphatic spaces, and occasionally in the blood-vessels. 

The lesions in the liver are of two kinds: firstly, local necroses of the 
parenchyma, scattered throughout the organ and possibly due to the action 
of chemical products of the amoebae; and, secondly, abscesses. These may 
be single or multiple. When single they are generally in the right lobe, 
either toward the convex surface near its diaphragmatic attachment, or 
on the concave surface in proximity to the bowel. Multiple abscesses are 
small and generally superficial. In an early stage the abscesses are grayish- 
yellow, with sharply defined contours, and contain a spongy necrotic ma- 
terial, with more or less fluid in its interstices. The larger abscesses have 
ragged necrotic walls, and contain a more or less viscid, greenish-yellow 
or reddish-yellow purulent material mixed with blood and shreds of liver- 
tissue. The older abscesses have fibrous walls of a dense, almost carti- 
laginous toughness. A section of the abscess wall shows an inner necrotic 
zone, a middle zone in which there is great proliferation of the connective- 
tissue cells and compression and atrophy of the liver-cells, and an outer 
zone of intense hyperaemia. There is the same absence of purulent inflam- 
mation as in the intestine, except in those cases in which a secondary in- 
fection with pyogenic organisms has taken place. The material from the 
abscess cavity shows chiefly fatty and granular detritus, few cellular ele- 
ments, and amoebae in variable numbers, which are also found in the abscess 
walls, chiefly in the inner necrotic zone. Mallory has devised a differential 
stain, by which they can be distinguished in tissues. Cultures are usually 
sterile. Lesions in the lungs are seen when an abscess of the liver — as so 
frequently happens — points toward the diaphragm and extends by con- 
tinuity through it into the lower lobe of the right lung. 

Symptoms. — The cases may be divided into the acute and chronic 
forms. 

Acute Amoebic Dysentery. — Many cases have an acute onset. Pain and 
tenesmus are severe. The stools are bloody, or mucus and blood. In very 
severe cases there may be constant tenesmus, with pain of the greatest 
intensity, and the passage every few minutes of a little blood and mucus. 
In some cases large sloughs are passed. The temperature as a rule is not 
high. The patient may become rapidly emaciated; the heart's action be- 
comes feeble, and death may occur within a week of the onset. Among the 
other symptoms to be mentioned are haemorrhage from the bowels, which 
occurred in seven cases; perforation of an ulcer, which occurred in four 
cases, with general peritonitis. While in a majority of the instances the 
patient recovers, in others the disease drags on and becomes chronic. • In 
a few cases, after the separation of the sloughs, there is extensive ulcera- 
tion remaining, with thickening and induration of the colon, and the 
patient has constant diarrhoea, loses weight, and ultimately dies exhausted, 
usually within three months of the onset. With the exception of cancer 



198 



SPECIFIC INFECTIOUS DISEASES. 



of the oesophagus and anorexia nervosa, no such extreme grade of emacia- 
tion is seen as in these cases. Extensive ulceration of the cornea may 
occur. 

Chronic Amoebic Dysentery. — The disease may be subacute from the 
onset, and gradually passes into a chronic stage, the special characteristic 
of which is alternating periods of constipation with diarrhoea. These may 
occur over a period of from six months to a year or more. Some of our 
patients have been admitted to the hospital five or six times within a 
period of two years. During the exacerbations there are pain, frequent 
passages of mucus and blood, and a slight rise of temperature. Many of 
these patients do not feel very ill, and retain their nutrition in a remark- 
able way; indeed, in this region it is rare in the chronic amoebic form to see 
the extreme emaciation so common in the chronic cases from the tropics. 
In them the alternating periods of improvement with attacks of diarrhoea 
are the rule. The appetite is capricious, the digestion disordered, and 
slight errors in diet are apt to be followed at once by an increase in the 
number of stools. The tongue is often red, glazed, and beefy. In pro- 
tracted cases the emaciation may be extreme. 

Acute Catarrhal Dysentery, Acute Ileo-colitis. — This may occur spo- 
radically or endemically, and is the variety most frequently found in tem- 
perate climates and in children. 

Morbid Anatomy. — The lesions are confined to the large bowel; some- 
times the ileum also is involved. The mucous membrane is injected, 
swollen, and often covered with tenacious blood-stained mucus. The most 
striking feature is the enlargement of the solitary follicles, which stand 
out prominently from the mucous membrane. In very acute forms, as in 
children, the picture is that of an acute follicular colitis. In more pro- 
tracted cases the follicles suppurate or are capped with an area of necrotic 
tissue. In other instances the sloughs have separated and the entire colon 
presents numerous ulcers, most of which have developed from the follicles, 
while others have resulted from necrosis and sloughing of the intervening 
tissue. 

Symptoms. — There may be preliminary dyspepsia or slight pains in the 
abdomen. Chills are rare. Diarrhoea is the most constant initial symp- 
tom, and at first is not painful. Usually within thirty-six hours the char- 
acteristic features of the disease develop — abdominal pain of a colicky, 
griping character and frequent stools, which are passed with straining and 
tenesmus; the constitutional disturbance is variable, and in mild cases 
may be slight. The temperature is not high; at the outset the range may 
be 10.2° or 103°. The tongue is furred and moist, and as the disease pro- 
gresses becomes red and glazed. Xausea and vomiting may be present, 
but, as a rule, the patient retains nourishment. The constant desire to go 
to stool and the straining or tenesmus are the most distressing symptoms. 
The abdomen may be flat and hard. The thirst is often excessive. The 
stools in this variety of dysentery have the following characters: During 
the first twenty-four or forty-eight hours they consist of more or less clear 
mucus and blood mixed with small faecal scybala. After this they become 
purely gelatinous and bloody, and are small and frequent, from fifteen to 



DYSENTERY. 



199 



two hundred in twenty-four hours, according to the severity of the case. 
About the end of the first week the mucus becomes opaque, the proportion 
of blood diminishes, and grayish or brownish shreddy material appears in 
the stools, which become gradually reduced in frequency. At this time 
they may be wholly composed of a greenish pultaceous material with mucus. 
As the disease subsides, faecal matter again appears in the stools, increasing 
in amount until they become normal. Microscopical examination of the 
glairy bloody stools shows red blood-corpuscles, few or many leucocytes, 
and constantly large, swollen, round or oval epithelioid cells, containing 
fat-drops and vacuoles. These are not infrequently mistaken for amoebae. 
Occasionally the cercomonas intestinalis is seen in large numbers. The ba- 
cillus pyocyaneus has been found by F. C. Curtis in a recent epidemic at 
Hartwick, N. Y. Not only was it present in the stools in large numbers, 
but it was isolated from the drinking-water in almost pure culture. 

Diphtheritic Dysentery. — A form of colitis or entero-colitis in which 
areas of necrosis occur in the mucous membranes, which on separation 
leave ulcers. This occurs: (a) As a primary disease coming on acutely 
and sometimes proving fatal. In its milder grades the tops of the folds 
of the colon are capped with a thin, yellow exudate. In severer forms 
the colon is enormously enlarged, the walls are thickened, stiff, and infil- 
trated, and the mucosa, from the ileo-caecal valve to the rectum, is repre- 
sented by a tough, yellowish material, in which on section no trace of the 
glandular elements can be seen. The condition is one of extensive necrosis 
of the mucosa. There are cases in which this necrosis is superficial, in- 
volving only the upper layers of the mucous membrane; but in the most 
advanced forms it may be, as in the description by Eokitansky, " a black, 
rotten, friable, charred mass." The areas of necrosis may be more local- 
ized, and large sloughs are formed which may be a half to three fourths 
of an inch in thickness and extend to the serosa. There are instances in 
which this condition is confined to the lower portion of the large bowel. 
In cases which last for many weeks the sloughs separate and may be 
thrown off, sometimes in large tubular pieces. The relation of this form 
to the specific dysentery of the tropics remains to be determined. 

(b) Secondary Diphtheritic Dysentery. — This occurs as a terminal event 
in many acute and chronic diseases. It is not infrequent in chronic heart 
affections, in Bright's disease, and in cachectic states generally. In acute 
diseases it is, as pointed out by Bristowe, most frequently associated with 
pneumonia. Anatomically there may be only a thin, superficial infiltra- 
tion of the upper layer of the mucosa in localized regions, particularly along 
the ridges and folds of the colon, often extending into the ileum. In 
severer forms the entire mucosa may be involved and necrotic, sometimes 
having a rough, granular appearance. In the secondary colitis of pneu- 
monia the exudation may be pseudo-membranous arid form a firm, thin, 
white pellicle which seems to lie upon, not within, the mucous membrane. 

Symptoms. — The clinical features of diphtheritic dysentery are very 
varied. In the acute primary cases the patient from the outset is often 
extremely ill, with high fever, great prostration, pain in the abdomen, and 
frequent discharges. Delirium may be early and the clinical features may 



200 



SPECIFIC INFECTIOUS DISEASES. 



closely resemble those of severe typhoid. I have, on more than one occa- 
sion, known this mistake to be made. The abdomen is distended and often 
tender. The discharges are frequent and diarrhceal in character, and tenes- 
mus may not be a striking symptom. Blood and mucus may be found early, 
but are not such constant features as in the follicular disease. This pri- 
mary form is very fatal, but the sloughs may separate and the condition 
become chronic. In the secondary form there may have been no symptoms 
to attract attention to the large bowel. In a majority of the cases the 
patient has a diarrhoea — three, four, or more movements in the day, which 
are often profuse and weakening. A little blood and mucus may be passed 
at first, but they are not specially characteristic elements in the stools. 

In all forms of dysentery death usually results from asthenia. The 
pulse becomes weaker and more rapid, the tongue dry, the face pinched, 
the skin cool and covered with sweat, and the patient falls into a drowsy, 
torpid condition. Consciousness may be retained until the last, but in 
the protracted cases there is a low delirium deepening into collapse. 

Complications and Sequelae of the Various Forms.— A 
local peritonitis may arise by extension, or a diffuse inflammation may fol- 
low perforation, which is usually fatal. When this occurs about the eaecal 
region, perityphlitis results; when low down in the rectum, periproctitis. 
In 108 autopsies collected by Woodward perforation occurred in 11. By far 
the most serious complication is abscess of the liver, which occurs fre- 
quently in the tropics and is not very uncommon in this country. It was 
not, however, a frequent complication in dysentery during the civil war. In 
this latitude it is certainly not uncommon. It usually comes on insidiously. 
The symptoms will be discussed in connection with hepatic abscess. 

In extensive epidemics, however, Woodward states that cases of ordinary 
dysentery occur associated with all the phenomena of malaria. We have 
had a number of instances of the coexistence of the two diseases. With 
reference to typhoid fever, as a complication, this author mentions that the 
combination was exceedingly frequent during the civil war, and charac- 
teristic lesions of both diseases coexisted. In civil practice it is extremely 
rare. 

Sydenham noted that dysentery was sometimes associated with rheu- 
matic pains, and in certain epidemics joint swellings have been especially 
prevalent. They are probably not of the nature of true rheumatism, but 
rather analogous to those of gonorrhceal arthritis. In severe, protracted 
cases there may be pleurisy, pericarditis, endocarditis, and occasionally pye- 
mic manifestations, among which may be mentioned pylephlebitis. Chronic 
Bright's disease is also an occasional sequel. In protracted cases there may 
be an anaemic oedema. An interesting sequel of dysentery is paralysis. 
Woodward reports 8 cases. Weir Mitchell mentions it as not uncommon, 
occurring chiefly in the form of paraplegia. As in other acute fevers, this 
is due probably to a neuritis. Intestinal stricture is a rare sequence — so 
rare that no case was reported at the Surgeon-General's office during the 
war. Among the sequelae of chronic dysentery, in persons who have recov- 
ered a certain measure of health, may be mentioned persistent dyspepsia 
and irritability of the bowels. 



DYSENTERY. 



201 



Diagnosis. — The recognition of the acute follicular form is easy; the 
frequency of the passages, the presence of blood and mucus, and the tenes- 
mus forming a very characteristic picture. Local affections of the rectum, 
particularly syphilis and epithelioma, may produce tenesmus with the 
passage of mucoid and bloody stools. The acute diphtheritic form, coming 
on with great intensity and with severe constitutional disturbances, is not 
infrequently mistaken for typhoid fever, to which indeed in many cases 
the resemblance is extremely close. The higher grade of fever, the more 
pronounced intestinal symptoms, the presence, particularly in the early 
stage, of a small amount of blood in the stools, the absence of enlargement 
of the spleen, the rose rash, and the Widal reaction should lead to a correct 
diagnosis. In the amoebic form the diagnosis can readily be made by ex- 
amination of the stools. A characteristic feature of these cases is their 
irregular, chronic course. A patient may be about and in fairly good con- 
dition, with well-formed stools and very slight intestinal disturbance, in 
whose faeces the amoeba? may still be discovered, and in whom the disease 
is at any time likely to recur with intensity. In some cases, complicated 
by abscess of the liver and lung discharging through a bronchus, the diag- 
nosis may rest on the detection of amoebae in the sputa, when they can not 
be found in the stools owing to the latency of the intestinal disturbance. 
Leucocytosis is rare except when complications arise. In the acute specific 
form the blood-serum agglutinates the Shiga bacillus. 

Treatment. — Flint has shown that sporadic dysentery is, in its 
slighter grades at least, a self-limited disease, which runs its course in eight 
or nine days. Reading a report of his cases, one is struck, however, with 
their comparative mildness.' 

The enormous surface involved, amounting to many square feet, the 
constant presence of irritating particles of food, and the impossibility of 
getting absolute rest, are conditions which render the treatment of dysen- 
tery peculiarly difficult. Moreover, in the severer cases, when necrosis of 
the mucosa has occurred, ulceration necessarily follows, and can not in any 
way be obviated. When a case is seen early, particularly if there has been 
constipation, a saline purge should be given. The free watery evacuations 
produced by a dose of salts cleanse the large bowel with the least possible 
irritation, and if necessary, in the course of the disease, particularly if 
scybala are present, the dose may be repeated. The saline treatment is 
much commended. W. J. Buchanan has treated 855 cases with only 9 
deaths. He gives a drachm of sodium sulphate, four, six, or eight times a 
day, and continues until all blood and mucus have disappeared, usually 
for two or three days. Of medicines which are supposed to have a direct 
effect upon the disease, ipecacuanha still maintains its reputation in the 
tropics. No food is taken for three hours, then twenty drops of laudanum, 
and half an hour after from 20 to 60 grains of ipecacuanha. If rejected 
by vomiting, the dose is repeated in a few hours. Washbourn ami Richards, 
in the South African campaign, speak of the good results of ipecacuanha 
combined with the saline treatment. 

Minute doses of corrosive sublimate, one hundredth of a grain every 
two hours, are warmly recommended by Ringer. Large doses of bismuth, 



202 



SPECIFIC INFECTIOUS DISEASES. 



half a drachm to a drachm every two hours, so that the patient may take 
from 12 to 15 drachms in a day, have in many cases had a beneficial effect. 
To do good it must be given in large doses, as recommended by Monneret, 
who gave as high as 70 grammes a day. It certainly is more useful in the 
chronic than the acute cases. It is best given alone. Opium is an invalu- 
able remedy for the relief of the pain and to quiet the peristalsis. It should 
be given as morphia, hypodermically, according to the needs of the patient. 

The treatment of dysentery by topical applications is by far the most 
rational ]3lan. A serious obstacle, however, in the acute cases, is the ex- 
treme irritability of the rectum and the tenesmus which follows any at- 
tempt to irrigate the colon. A preliminary cocaine suppository or the in- 
jection of a small quantity of the 4-per-cent solution will sometimes re- 
lieve this, and then with a long tube the solution can be allowed to flow 
in slowly. The patient should be in the dorsal position with a pillow under 
the hips, so as to get the effect of gravitation. Water at the temperature 
of 100° is very soothing, but the irritability of the bowel is such that large 
quantities can rarely be retained for any time. "When the acute symptoms 
subside, the injections are better borne. Various astringents may be used — 
alum, acetate of lead, sulphate of zinc and copper, and nitrate of silver. 
Of these remedies the nitrate of silver is the best, though, I think, not in 
very acute cases. In the chronic form it is perhaps the most satisfactory 
method of treatment which we have. It is useless to give it in the small 
injections of two or three ounces with 1 to 2 grains of the salt to the 
ounce. It must be a large irrigating injection, which will reach all parts 
of the colon. This plan was introduced by Hare, of Edinburgh, and is 
highly recommended by Stephen Mackenzie and H. C. Wood. The solu- 
tion must be fairly strong, 20 to 30 grains to the pint, and if possible from 
3 to 6 pints of fluid must be injected. To begin with it is well to use 
not more than a drachm to the 2 pints or 2J pints, and to let the warm 
fluid run in slowly through a tube passed far into the bowel. It is at times 
intensely painful and is rejected at once. Argyria, so far as I know, has 
never followed the prolonged use of nitrate-of-silver injections in chronic 
dysentery. In the cases of amoebic dysentery we have been using at the 
Johns Hopkins Hospital with great benefit warm injections of quinine in 
strength of 1 to 5,000, 1 to 2,500, and 1 to 1,000. The amcebsB are rapidly 
destroyed by the drug. These large injections are said not to be without 
a certain degree of clanger. I have never seen any ill effects, even with 
the very large amounts. When there is not much tenesmus, a small in- 
jection of thin starch with half a drachm to a drachm of laudanum gives 
great relief, but for the tormina and tenesmus, the two most distressing 
symptoms, a hypodermic of morphia is the only satisfactory remedy. Local 
applications to the abdomen, in the form of light poultices or turpentine 
stupes, are very grateful. 

The diet in acute cases must be restricted to milk, whey, and broths, 
and during convalescence the greatest care must be taken to provide only 
the most digestible articles of food. In chronic dysentery, diet is perhaps 
the most important element in the treatment. The number of stools can 
frequently be reduced from ten or twelve in the day to two or three, by 



MALARIAL FEVER. 



203 



placing the patient in bed and restricting the diet. Many cases do well 
on milk alone, but the stools should be carefully watched and the amount 
limited to that which can be digested. If curds appear, or if much oily 
matter is seen on microscopical examination, it is best to reduce the 
amount of milk and to supplement it with beef-juice or, better still, egg- 
albumen. The large doses of bismuth seem specially suitable in the chronic 
cases, and the injections of nitrate of silver, in the way already mentioned, 
.should always be given a trial. 

XXIV. MALARIAL FEVER. 

Definition. — An infectious disease characterized by: (a) paroxysms of 
intermittent fever of quotidian, tertian, or quartan type; (b) a continued 
fever with marked remissions; (c) certain pernicious, rapidly fatal forms; 
and (d) a chronic cachexia, with anaemia and an enlarged spleen. 

With the disease are invariably associated the hasmocytozoa described 
by Laveran, which are transmitted to man by the bite of the mosquito. 

Etiology. — (1) Geographical Distribution. — In Europe, southern 
Russia and certain parts of Italy are now the chief seats of the disease. It 
is rare in Germany, France, and England, and the foci of epidemics are 
becoming yearly more restricted. 

In the United States malaria has progressively diminished in extent 
and severity during the past fifty years. The records of the health boards 
of the larger cities on the Atlantic coast which give a high mortality from 
the disease are quite untrustworthy. From New England, where it once 
prevailed extensively, it has gradually disappeared, but there has of late 
years been a slight return in some places. In the city of New York the 
milder forms of the disease are not uncommon. In Philadelphia and along 
the valleys of the Delaware and Schuylkill Eivers, formerly hot-beds of 
malaria, the disease has become much restricted. In Baltimore a few cases 
develop in the autumn, but a majority of the patients seeking relief are 
from the outlying districts and one or two of the inlets of Chesapeake Bay. 
Throughout the Southern States there are many regions in which malaria 
prevails; but here, too, the disease has diminished in prevalence and in- 
tensity. In the Northwestern States malaria is almost unknown. It is rare 
on the Pacific coast. In the region of the Great Lakes malaria prevails 
only in the Lake Erie and Lake St. Clair regions. The St. Lawrence 
basin remains free from the disease. 

In India malaria is very prevalent, particularly in the great river basins. 
In Burma and Assam severe types are met with, and recently the anomalous 
form of fever known as the Kdla-dzar of Assam has been shown to be ma- 
larial (Rogers). 

In Africa the malarial fevers form the great obstacle to European set- 
tlements on the coast and along the river basins. The black-water or West 
African fever of the Gold Coast is a very fatal type of malarial haemo- 
globinuria. 

(2) Season.— In the tropics there are minimal and maximal periods, 
the former corresponding to the summer and winter, the latter to the 
13 



204 



SPECIFIC INFECTIOUS DISEASES. 



spring and antnmn months. In temperate regions, like the central Atlan- 
tic States, there are only a few cases in the spring, usually in the month of 
May, and a large number of eases in September and October, and some- 
times in November. 

(3) The Parasite. — Parasites of the red blood-corpuscles — hamiocy- 
tozoa or hsemosporidia — are very widespread throughout the animal series. 
They are met with in the blood of frogs, fish, birds, and among mammals 
in monkeys, bats, cattle, and man. In birds and in frogs the parasites 
appear to do no harm except when present in very large numbers. 

In 1880 Laveran, a French army surgeon stationed at Algiers, noted in 
the blood of patients with malarial fever pigmented bodies, which he 
regarded as parasites, and as the cause of the disease. Eichard, another 
French army surgeon, confirmed these observations. In 1885 Marchiafava 
and Celli described the parasites with great accuracy, and in the same 
year Golgi made the all-important observation that the paroxysm of fever 
invariably coincided with the sporulation or segmentation of a group of 
the parasites. In the following year (1886) Laveran's observations were 
brought before the profession in this country by Sternberg. Councilman 
and Abbott had already, in the previous year, described the remarkable pig- 
mented bodies in the red blood-corpuscles in the blood-vessels of the brain 
in a fatal case, and in 1886 Councilman confirmed the observations of 
Laveran in clinical cases. Stimulated by his work, I began studying the 
malarial cases in the Philadelphia Hospital, and soon became convinced of 
the truth of Laveran's discovery, and was able to confirm Golgi's statement 
as to the coincidence of the sporulation with the paroxysm. The work 
was taken up actively in this country by Walter James, Dock, Koplik, 
Thayer, Hewetson, and others, and in a number of subsequent communica- 
tions I tried to emphasize the extraordinary clinical importance of Lav- 
eran's discovery.* 

Among British observers, Vandyke Carter alone, in India, seems to have 
appreciated at an early date the profound significance of Laveran's work. 

The next important observation was the discovery by Golgi that the 
parasite of quartan malarial fever was different from the tertian. From this- 
time on the Italian observers took up the work with great energy, and in 
1889 Marchiafava and Celli determined that the organism of the severer 
forms of malarial fever differed from the parasite of the tertian and quar- 
tan varieties. During the past ten years the work of observers in many 
lands has confirmed these essential features, and has added greatly to our 
knowledge of the structure and modes of development of the parasites. 



* The following references to work on malaria which has been done in connection 
with my clinic, chiefly under the supervision of my colleague, Professor Thayer, may be 
of interest : Philadelphia Medical Times, 1886 ; British Medical Journal, March, 1887 ; 
Medical News, 1889, vol. i ; Johns Hopkins Hospital Bulletin, 1889 ; the first edition of 
my Text-Book of Medicine, 1892 ; Thayer and Hewetson, Johns Hopkins Hospital Reports, 
1895; Thayer, Lectures on Malarial Fever, 1897; W. G. MacCallum, Haematozoa of Birds, 
Jour, of Exp. Med., 1898 ; Opie, On the Haematozoa of Birds, 1898 ; Barker, On Fatal Cases 
of Malaria, Johns Hopkins Hospital Reports, 1899 ; MacCallum, On the Significance of the 
Flagella, Lancet, 1897; Thayer, Transactions American Medical Congress, vol. iv, 1900. 



MALARIAL FEVER. 



205 



The next important step related to the question of the mode of infec- 
tion. It had been suggested by King, of Washington, and others, that the 
disease was transmitted by the mosquitoes. The important role played 
by insects as an intermediate host had been shown in the case of the Texas 
cattle fever, in which Theobald Smith demonstrated that the hamiatozoa 
developed in, and the disease was transmitted by, ticks; but it remained 
for Hanson to formulate in a clear and scientific way the theory of infec- 
tion in malaria by the mosquito. Impressed with the truth of this, Eoss 
studied the problem in India, and showed that the parasites developed in 
the bodies of the mosquitoes, and demonstrated conclusively that the 
infection in birds was transmitted by the mosquito. W. G. MacCallum 
suggested that the flagella were sexual elements, and he actually saw the 
process of fertilization by them. 

In many countries the forms of mosquitoes were studied, and it was 
demonstrated that the malarial infection was associated with special vari- 
eties, and Grassi and others confirmed Eoss's discovery of development of 
the parasites in the body of the mosquito. Then came the practical 
demonstration by Italian observers, and by the interesting experiments on 
Manson, Jr., of the direct transmission of the disease to man by the bite 
of infected mosquitoes. And lastly, as a practical conclusion of the whole 
matter, is the war against the mosquito and the recognition of the means 
whereby infection may be prevented. 

General Morphology of the Parasite. — Belonging to the sporozoa, it has 
received a large number of names, of which, perhaps, hsemamceba is at 
present the most satisfactory. The term plasmodium malaria? has also been 
applied to the parasite as it exists in the human blood. There are three, 
possibly more, well-marked varieties of the parasite, and they exist in two 
separate phases or stages: (a) the parasite in man, who acts as the interme- 
diate host, and in whom, in the cycle of its development, it causes symptoms 
of malaria; and (b) an extracorporeal cycle, in which it lives and develops in 
the body of the mosquito, which is its definitive host. 

I. The Parasite in Man. — (a) The Parasite of Tertian Fever. — The ear- 
liest form seen in the red blood-corpuscle is oval or irregular in shape, about 
2 fi in diameter and unpigmented. It corresponds very much in appear- 
ance with the spore bodies of the rosettes formed during the chill. A few 
hours later the body has increased in size, is still ring-shaped, and there 
is pigment in the form of fine grains. It has a relatively large nuclear body, 
consisting of a well-defined, clear area, in part almost transparent, in part 
consisting of a milk-white substance, in which there lies a small, deeply 
staining chromatin mass, as shown by Eomanowsky's method of staining. 
At this period it usually shows active amoeboid movements, with tongue- 
Like protrusions. The pigment increases in amount and the corpuscle he- 
roines larger and paler, owing to a progressive diminution of its haemo- 
globin. There is a gradual growth of the parasite, which, toward the end 
of twenty-four hours, occupies almost all of the swollen rod corpuscle. 
It is now much pigmented, and is in the stage of what is often called the 
full-grown parasite. Between the twentieth and twenty-fourth hours many 
of the parasites are seen to have undergone the remarkable change known 



206 



SPECIFIC INFECTIOUS DISEASES. 



as segmentation, in which the pigment becomes collected into a single mass 
or block, and the protoplasm divides into a series of from fifteen to twenty 
spores, often showing a radial arrangement. Certain full-grown tertian 
parasites, however, do not undergo segmentation. These forms, which are 
larger than the sporulating bodies, and contain very actively dancing pig- 
ment grannies, represent the sexually differentiated form of the parasite — 
gametocytes. 

(b) The Parasite of Quartan Fever. — The earliest form is very like the 
tertian in appearance, but as it increases in size the earlier granules are 
coarser and darker and the movement is not nearly so marked. By the 
third day the parasite is still larger, rounded in shape, scarcely at all 
amoeboid, and the pigment is more often arranged at the periphery of the 
parasite. The rim of protoplasm about it is often of a deep yellowish- 
green color or of a dark brassy tint. On the fourth day the segment- 
ing bodies become abundant, the pigment flowing in toward the centre 
of the parasite in radial lines so as to give a star-shaped appearance. The 
parasites finally break up into from six to twelve spores. Here also, as 
in the case of the tertian parasite, some full-grown bodies persist without 
sporulating, representing the gametocytes. 

(c) The parasite of the cestivo-autumnal fever is considerably smaller than 
the other varieties; at full development it is often less than one half 
the size of a red blood-corpuscle. The pigment is much scantier, often 
consisting of a few minute granules. At first only the earlier stages of 
development, small, hyaline bodies, sometimes with one or two pigment 
granules, are to be found in the peripheral circulation; the later stages are 
ordinarily only to be seen in the blood of certain internal organs, the spleen 
and bone marrow particularly. The corpuscles containing the parasites 
become not infrequently shrunken, crenated, and brassy-colored. After 
the process has existed for about a week, larger, refractive, crescentic, 
ovoid, and round bodies, with central clumps of coarse pigment granules, 
begin to appear. These bodies are characteristic of sestivo-autumnal fever. 
The crescentic and ovoid forms are incapable of sporulation; they are 
analogous to the large, full-grown, non-sporulating bodies of the tertian 
and quartan parasites which have been above mentioned, and represent 
sexually differentiated forms — gametocytes. Within the human host they 
are incapable of further development, but upon the slide, or within the 
stomach of the normal intermediate host, the mosquito, the male ele- 
ments (micro-gametocytes) give rise to a number of long, actively motile 
flagella (micro-gametes) which break loose, penetrating and fecundating 
the female forms — macro-gametes (W. G. MacCallum). The fecundated 
female form enters into the stomach wall of the intermediate host, the 
mosquito, where it undergoes a definite cycle of existence. 

II. The Parasite within the Body of the Mosquito. — The brilliant re- 
searches of Eoss, followed by the work of Grassi, Bastianelli, Bignami, 
Stephens, Christophers, and Daniels, have proved that a certain genus 
of mosquito — anopheles — is not only the intermediate host of the malarial 
parasite, but also the sole source of infection. In the present state of our 
knowledge it would appear that all species of the genus anopheles may act 



MALARIAL FEVER. 



207 



as hosts of the parasite. The more common genera of mosquito in tem- 
perate climates are cnlex and anopheles. The different species of culex 
form the great majority of our ordinary house mosquitoes, and are appar- 
ently incapable of acting as hosts of the malarial parasite. All malarial 
regions, however, which have been investigated contain anopheles. Al- 
though this is apparently a positive rule, anopheles may, however, be pres- 
ent without the existence of malaria under two circumstances: firstly, 
when the climate is too cold for the development of the malarial parasite; 
and secondly, in a region which has not yet been infected. So far as is 
known, the parasite exists only in the mosquito and in man. It is apparently 
fair to state that regions in which mosquitoes of the genus anopheles are 
present may become malarious during the warm season. A large number 
of species of anopheles have been described. In this country, however, only 
three have been positively recognized — A. punctipennis (Say), A. quadri- 
maculatus (Say), A. crucians (Wied). The commonest variety, and that 
which in all probability is most concerned in the spread of the disease in 
this country, is A. quadrimaculatus, which has been shown to be identical 
with A. claviger (A. maculipennis), which is the most important agent in 
the spread of the disease on the Continent. 

Mr. Howard, of the Entomological Department at Washington, has 
issued a very useful pamphlet on the varieties and the methods of 
identification. In Africa the distribution of the forms has been studied by 
Stephens, Christophers, and Daniels. To those interested in the subject, 
Christophers' careful study of the Anatomy and Histology of the Adult 
Female Mosquito (Eeport of Malaria Committee, Eoyal Society, No. IX) 
will prove of great help. 

The palpi in the mature culex are extremely short, only to be seen on 
careful observation at the base of the proboscis, while in the anopheles 
they are nearly of equal length with the proboscis, so that on superficial 
observation the insect would appear to have three proboscides. The wings 
of the common species of culex show no markings beyond the ordinary 
veins. The wings of all our American species of anopheles show distinct 
mottling. The culex, when sitting upon the wall or ceiling, holds its pos- 
terior pair of legs turned up above its back, while the body lies nearly 
parallel to the wall. In some instances, when it is full of blood, and sit- 
ting upon the ceiling, the body may sag downward considerably. The 
anopheles, when sitting upon the wall or ceiling, holds its posterior pair 
of legs commonly either against the wall or hanging downward, though in 
some instances they may be lifted above the back. The body, however, in- 
stead of lying parallel to the wall or ceiling, protrudes at an angle of 45° 
or more. These simple points are sufficient to permit the ready distinct ion 
of species by almost any individual. 

The culex lays its eggs in sinks, tanks, cisterns, and any collection of 
water about or in houses, while anopheles lays its eggs in small, shallow 
puddles or slowly running streams, especially those in which certain forms 
of algae exist. The culex is essentially a city mosquito, the anopheles a 
country insect. 

Evolution in the Body of the Mosquito. — When a mosquito of tin 



208 



SPECIFIC INFECTIOUS DISEASES. 



genus anopheles bites an individual whose blood contains sex-ripe forms 
(gametocytes) of the malarial parasite, flagellation and fecundation of the 
female element occurs within the stomach of the insect. The fecundated 
element then penetrates the wall of the mosquito's stomach and begins a 
definite cycle of development in the muscular coat. Two days after biting 
there begin to appear small, round, refractive, granular bodies in the 
stomach wall of the mosquito, which contain pigment granules clearly 
identical with those previously contained in the malarial parasite. These 
develop until at the end of seven days they have reached a diameter of 
from 60 to 70 fx. At this period they may be observed to show a delicate 
radial striation due to the presence of great numbers of small sporoblasts. 
The mother oocyst (zygote) then bursts, setting free into the body cavity 
of the mosquito an enormous number of delicate spindle-shaped sporo- 
zoids. These accumulate in the cells of the veneno-salivary glands of the 
mosquito, and, escaping into the ducts, are inoculated with subsequent 
bites of the insect. These little spindle-shaped sporozoids develop, after 
inoculation into the warm-blooded host, into fresh young parasites. The 
sporozoid which has developed in the oocyst in the stomach wall of the mos- 
quito is then the equivalent of the spore resulting from the asexual seg- 
mentation of the full-grown parasite in the circulation. Either one, on 
entering a red blood-corpuscle, may give rise to the asexual or sexual cycle. 
As a rule the first several generations of parasites in the human body pur- 
sue the asexual cycle, the sexual forms developing later. These sexual 
forms, sterile while in the human host, serve as the means of preserving 
the life of the parasite and spreading infection when the individual is 
subjected to bites of anopheles. 

Morbid Anatomy. — The changes result from the disintegration of 
the red blood-corpuscles, accumulation of the pigment thereby formed, and 
possibly the influence of toxic materials produced by the parasite. Cases 
of simple malarial infection, the ague, are rarely fatal, and our knowledge 
of the morbid anatomy of the disease is drawn from the pernicious malaria 
or the chronic cachexia. Eupture of the enlarged spleen may occur spon- 
taneously, but more commonly from trauma. A case of the kind was ad- 
mitted under my colleague, Halsted, in June, 1889, and Dock has reported 
two cases. 

(1) Pernicious Malaria. — The blood is hydremic and the serum may 
even be tinged with haemoglobin. The red blood-corpuscles present the 
endogiobular forms of the parasite and are in all stages of destruction. 
The spleen is enlarged, often only moderately; thus, of two fatal cases 
in my wards the spleens measured 13 X 8 cm. and 14 X 8 cm. respec- 
tively. In a fresh infection, the spleen is usually very soft, and the pulp 
lake-colored and turbid. The liver is swollen and turbid. 

In some acute pernicious cases with choleraic symptoms, the capillaries 
of the gastro-intestinal mucosa may be packed with parasites. 

(2) Malarial Cachexia. — In fatal cases of chronic paludism death occurs 
usually from anaemia or the haemorrhage associated with it. 

The anaemia is profound, particularly if the patient has died of fever. 
The spleen is greatly enlarged, and may weigh from seven to ten pounds. 



MALARIAL FEVER. 



209 



The liver may be greatly enlarged, and presents to the naked eye a 
grayish-brown or slate color, due to the large amount of pigment. In 
the portal canals and beneath the capsule the connective tissue is im- 
pregnated with melanin. The pigment is seen in the Kupffer's cells and 
the perivascular tissue. 

The kidneys may be enlarged and present a grayi§h-red color, or areas 
of pigmentation may be seen. The peritonaeum is usually of a deep slate- 
color. The mucous membrane of the stomach and intestines may have 
the same hue, due to the pigment in and about the blood-vessels. In 
some cases this is confined to the lymph nodules of Peyer's patches, caus- 
ing the shaven-beard appearance. 

(3) The Accidental and Late Lesions of Malarial Fever. — (a) The Liver. — 
Paludal hepatitis plays a very important role in the history of malaria, as 
described by French writers. Only those cases in which the history of 
chronic malaria is definite, and in which the melanosis of both liver and 
spleen coexist, should be regarded as of paludal origin. 

(b) Pneumonia is believed by many authors to be common in malaria, 
and even to depend directly upon the malarial poison, occurring either in 
the acute or in the chronic forms of the disease. I have no personal 
knowledge of such a special pneumonia. 

(c) Nephritis. — Moderate albuminuria is a frequent occurrence, having 
occurred in 46.4 per cent of the cases in my wards. Acute nephritis is 
relatively frequent in aastivo-autumnal infections, having occurred in over 
4.5 per cent of my cases. Chronic nephritis occasionally follows long- 
continued or frequently repeated infections. 

Clinical Forms of Malarial Fever.— (1) The Regularly Inter- 
mittent Fevers. — (a) Tertian fever; (b) quartan fever. These forms are 
characterized by recurring paroxysms of what are known as ague, in which, 
as a rule, chill, fever, and sweat follow each other in orderly sequence. The 
stage of incubation is not definitely known; it probably varies much ac- 
cording to the amount of the infectious material absorbed. Experimentally 
the period of incubation varies from thirty-six hours to fifteen days, being 
a trifle longer in quartan than in tertian infections. Attacks have been 
reported within a very short time after the apparent exposure. On the 
other hand, the ague may be, as is said, " in the system," and the patient 
may have a paroxysm months after he has removed from a malarial region, 
though of course this can not be the case unless he has had the disease 
when living there. 

Description of the Paroxysm. — The patient generally knows he is going 
to have a chill a few hours before its advent by unpleasant feelings and 
uneasy sensations, sometimes by headache. The paroxysm is divided into 
three stages — cold, hot, and sweating. 

Cold Stage. — The onset is indicated by a feeling of lassitude 1 and a 
desire to yawn and stretch, by headache, uneasy sensations in the epigas- 
trium, sometimes by nausea and vomiting. Even before the chill begins 
the thermometer indicates some rise in temperature. Gradually the pa- 
tient begins to shiver, the face looks cold, and in the fully developed rigor 
the whole body shakes, the teeth chatter, and the movements may often 



210 



SPECIFIC INFECTIOUS DISEASES. 




Chart XI b. — JEstivo-autumnal infection. — Remittent fever. 
The case was treated for a week as one of typhoid fever. 



MALARIAL FEVER. 



211 




July 19 20 21 22 23 24 




Chart XI d.— Quartan fever. 



212 



SPECIFIC INFECTIOUS DISEASES. 



be violent enough to shake the bed. Not only does the patient look cold 
and blue, but a surface thermometer will indicate a reduction of the skin 
temperature. On the other hand, the axillary or rectal temperature may, 
during the chill, be greatly increased, and, as shown in the chart, the fever 
may rise meanwhile even to 105° or 106°. Of symptoms associated with 
the chill, nausea and vomiting are common. There may be intense head- 
ache. The pulse is quick, small, and hard. The urine is increased in 
quantity. The chill lasts for a variable time, from ten or twelve minutes 
to an hour, or even longer. 

The hot stage is ushered in by transient flushes of heat; gradually the 
coldness of the surface disappears and the skin becomes intensely hot. 
The contrast in the patient's appearance is striking: the face is flushed, 
the hands are congested, the skin is reddened, the pulse is full and bound- 
ing, the heart's action is forcible, and the patient may complain of a throb- 
bing headache. There may be active delirium. A patient in this stage 
jumped through a ward window and sustained fatal injuries. The rectal 
temperature may not increase much during this stage; in fact, by the 
termination of the chill the fever may have reached its maximum. The 
duration of the hot stage varies from half an hour to three or four hours. 
The patient is intensely thirsty and drinks eagerly of cold water. 

Sweating Stage. — Beads of perspiration appear upon the face and grad- 
ually the entire body is bathed in a copious sweat. The uncomfortable 
feeling associated with the fever disappears, the headache is relieved, and 
within an hour or two the paroxysm is over and the patient usually sinks 
into a refreshing sleep. The sweating varies much. It may be drenching 
in character or it may be slight. 

Chart XI a is from a case of double tertian infection with resulting 
quotidian paroxysms. Charts XI & and XI c give temperature curves in 
sestivo-autumnal forms. Chart XI d shows a quartan ague. 

The total duration of the paroxysm averages from ten to twelve hours, 
but may be shorter. Variations in the paroxysm are common. Thus the 
patient may, instead of a chill, experience only a slight feeling of coldness. 
The most common variation is the occurrence of a hot stage alone, or with 
very slight sweating. During the -paroxysm the spleen is enlarged and 
the edge can Usually be felt below the costal margin. In the interval or 
intermission of the paroxysm the patient feels very well, and, unless the 
disease is unusually severe, he is able to be up. Bronchitis is a common 
symptom. Herpes, usually labial, is perhaps as frequently seen in ague as 
in pneumonia. 

Types of the Regularly Intermittent Fevers. — As has been stated in the 
description of the parasites, two distinct types of the regularly intermit- 
tent fevers have been separated. These are (a) tertian fever and (b) quartan 
fever. 

(a) Tertian Fever. — This type of fever depends upon the presence in 
"the blood of the tertian parasite, an organism which, as stated above, is 
usually present in sharply defined groups, whose cycle of development lasts 
approximately forty-eight hours, sporulation occurring every third day. 
In infections with one group of the tertian parasite the paroxysms occur 



MALARIAL FEVER. 



213 



synchronously with sporulation at remarkably regular intervals of about 
forty-eight hours, every third day — hence the name tertian. Very com- 
monly, however, there may be two groups of parasites which reach maturity 
on alternate days, resulting thus in daily (quotidian) paroxysms — double 
tertian infection. Quotidian fever, depending upon double tertian infec- 
tion, is the most frequent type in the acute intermittent fevers in this 
latitude. 

(b) Quartan Fever. — This type of fever depends upon infection with 
the quartan parasite, an organism which occurs in well-defined groups, 
whose cycle of existence lasts about seventy-two hours. In infection with 
one group of parasites the paroxysm occurs every fourth day; hence the 
term quartan. At times, however, two groups of the parasites may be 
present; under these circumstances paroxysms occur on two successive 
days, with a day of intermission following. In infection with three groups 
of parasites there are daily paroxysms. 

Thus a quotidian intermittent fever may be due to infection with 
either the tertian or quartan parasites. 

Course of the Disease. — After a few paroxysms, or after the disease has 
persisted for ten clays or two weeks, the patient may get well without any 
special medication. I have repeatedly known the chills to stop spontane- 
ously. Such cases, however, are very liable to recurrence. Persistence of 
the fever leads to anaemia and haematogenous jaundice, owing to the de- 
struction of the red blood-disks by the parasites. Ultimately the condition 
may become chronic, and will be described under malarial cachexia. The 
Tegularly intermittent fevers yield promptly and immediately to treatment 
with quinine. 

(2) The more Irregular, Remittent, or Continued Fevers. — iEstivo 
autumnal Fever. — This type of fever occurs in temperate climates, chiefly 
in the later summer and fall; hence the term given to it by Marchiafava 
and Celli, cestivo-autumnal fever. The severer forms of it prevail in the 
Southern States and in tropical countries, where it is known chiefly as 
'bilious remittent fever. The entire group of cases included under the terms 
remittent fever, bilious remittent, and typlio-malarial fevers requires to be 
studied anew. 

This type of fever is associated with the presence in the blood of the 
asstivo-autumnal parasite, an organism the length of whose cycle of de- 
velopment is probably subject to variations, while the existence of multiple 
groups of the parasite, or the absence of arrangement into definite groups, 
is not infrequent. 

The symptoms are therefore, as might be expected, often irregular. In 
some instances there may be regular intermittent fever occurring at uncer- 
tain intervals of from twenty-four to forty-eight hours, or even more. In 
the cases with longer remissions the paroxysms are longer. Some of the 
quotidian intermittent eases may closely resemble the quotidian fever de- 
pending upon double tertian or triple quartan infection. Commonly, how- 
ever, the paroxysms show material differences; their length averages over 
twenty hours, instead of from ten or twelve; the onset occurs often with- 
out chills and even without chilly sensations. The rise in temperature is 



214 



SPECIFIC INFECTIOUS DISEASES. 



frequently gradual and slow, instead of sudden, while the fall may occur 
by lysis instead of by crisis. There is a marked tendency toward anticipa- 
tion in the paroxysms, while frequently, from the anticipation of one parox- 
ysm or the retardation of another, more or less continuous fever may 
result. Sometimes there is continuous fever without sharp paroxysms. In 
these eases of continuous and remittent fever the patient, seen fairly early 
in the disease, has a flushed face and looks ill. The tongue is furred, the 
pulse is full and bounding, but rarely dicrotic. The temperature may range 
from 102° to 103°, or is in some instances higher. The general appear- 
ance of the patient is strongly suggestive of typhoid fever — a suggestion 
still further borne out by the existence of acute splenic enlargement of 
moderate grade. As in intermittent fever, an initial bronchitis may be 
present. The course of these cases is variable. The fever may be con- 
tinuous, with remissions more or less marked; definite paroxysms with or 
without chills may occur, in which the temperature rises to 105° or 106°. 
Intestinal symptoms are usually absent. A slight hematogenous jaundice 
may develop early. Delirium of a mild type may occur. The cases vary 
very greatly in severity. In some the fever subsides at the end of the week, 
and the practitioner is in doubt whether he has had to do with a mild 
typhoid or a simple febricula. In other instances the fever persists for 
from ten days to two weeks; there are marked remissions, perhaps chills, 
with a furred tongue and low delirium. Jaundice is not infrequent. These 
are the cases to which the term bilious remittent and typlio-malarial fevers 
are applied. In other instances the symptoms become grave and assume 
the character of the pernicious type. It is in this form of malarial fever that 
so much confusion still exists. The similarity of the cases to typhoid fever 
is most striking, more particularly the appearance of the faqies, and the 
patient looks very ill. The cases develop, too, in the autumn, at the very 
time when typhoid fever occurs. The fever yields, as a rule, promptly 
to quinine, though here and there cases are met with — rarely indeed in my 
experience — which are refractory. It is just in this group that the observa- 
tions of Laveran will be found of the greatest value. Several of the charts 
in Thayer and Hewetson's report show how closely, in some instances, 
the disease may simulate typhoid fever. 

The diagnosis of malarial remittent fever may be definitely made by 
the examination of the blood. The small, actively motile, hyaline forms 
of the aestivo-autumnal parasite are to be found, while, if the case has 
lasted over a week, the larger erescentic and ovoid bodies are usually seen. 
In many cases here we are at first unable to distinguish between typhoid 
and continued malarial fever without a blood examination. A more wide- 
spread use of this means of diagnosis will enable us to bring some order 
out of the confusion which exists in the classification of the fevers of the 
South. At present the following febrile affections are recognized by vari- 
ous physicians as occurring in the subtropical regions of this continent: 
(a) Typhoid fever; (b) typho-malarial fever — a typhoid modified by ma- 
larial infection, or the result of a combined infection; (c) the malarial 
remittent fever; and (d) continued thermic fever (Gruiteras). In these 
various forms, all of which may be characterized by a continued pyrexia 



MALARIAL FEVER. 



215 



with remissions or with chills and sweats (for we must remember that chills 
and sweats in typhoid fever are by no means rare), the blood examination 
will enable us to discover those which depend upon the malarial poison. 
In many of these cases of continued or remittent fever careful inquiry 
will show that at the beginning the patient had several intermittent parox- 
ysms. In this latitude we have not the opportunity of seeing many of 
the protracted and severe cases, but I am inclined to think that future 
observations will show that, apart from the thermic fever, there are only 
two forms of these continued fevers in the South — the one due to the 
typhoid and the other to the malarial infection. The typhoid fever of 
Philadelphia and Baltimore presents no essential difference from the dis- 
ease as it occurs in Montreal, a city practically free from malaria. Dock 
has shown conclusively that cases diagnosed in Texas as continued malarial 
fever were really true typhoid. The Widal reaction is now an important 
aid in diagnosis. 

Pernicious Malarial Fever. — This is fortunately rare in temperate cli- 
mates, and the number of cases which now occur, for example, in Phila- 
delphia and Baltimore, is very much less than it was thirty or forty years 
ago. Among the cases of malaria which have been under observation during 
the past eight years there were only seven of the pernicious form. Per- 
nicious fever is always associated with the sestivo-autumnal parasite. The 
following are the most important types: 

(a) The comatose form, in which a patient is struck down with symp- 
toms of the most intense cerebral disturbance, either acute delirium or, 
more frequently, a rapidly developing coma. A chill may or may not pre- 
cede the attack. The fever is usually high, and the skin hot and dry. 
The unconsciousness may persist for from twelve to twenty-four hours, or 
the patient may sink and die. After regaining consciousness a second 
attack may come on and prove fatal. In these instances, as has been stated, 
the special localization of the infection is in the brain, where actual thrombi 
■of parasites with marked secondary changes in the surrounding tissues have 
been found. 

(b) Algid Form. — In this, the attack sets in usually with gastric symp- 
toms; there are vomiting, intense prostration, and feebleness out of all 
proportion to the local disturbance. The patient complains of feeling cold, 
although there may be no actual chill. The temperature may be normal, 
or even subnormal; consciousness may be retained. The pulse is feeble 
and small, and the respirations are increased. There may be most severe 
diarrhoea, the attack assuming a choleriform nature. The urine is often 
diminished, or even suppressed. This condition may persist with slight 
•exacerbations of fever for several days and the patient may die in a condi- 
tion of profound asthenia. This is essentially the same as described as 
the asthenic or adynamic form of the disease. In the cases with vomiting 
and diarrhoea, Marchiafava has shown that the gastro-intcstinal mucosa is 
often the seat of a special invasion by the parasites, actual thrombosis of 
the small vessels with superficial ulceration and necrosis occurring. Simi- 
lar lesions were found by Barker in the gastro-intestinal tract of a case 
from my wards. 



216 



SPECIFIC INFECTIOUS DISEASES. 



(c) Hcemorrhagic Forms — Black-water Fever — Haimoglobinuric Fever — 
Malarial Hcemoglooinuria. — In temperate regions these forms are rare; in 
the tropics they are common. In the Southern States there are many 
districts in which there is endemic hemoglobinuria, believed to be of ma- 
larial origin, while in parts of Africa there is the much-disputed malady 
known as black-water fever. There seems to be no essential difference be- 
tween the malarial hemoglobinuria of the Southern States and the African, 
black-water fever. As described by Stephens and Christophers (Eeport of 
Malaria Committee, Fifth Series), for two or three days the patient has 
a rise of temperature, and if the blood is examined before the black-water 
the parasites are almost invariably present. If examined after the ad- 
ministration of quinine parasites are absent from the blood. These authors 
agree with the generally expressed opinion of physicians in the Southern 
States, that there is a causal connection between the quinine and the 
black-water. It is impossible to say why quinine at one time can produce 
black-water, and at another, even a few hours or days later, it can not. Of 
the 16 cases of black-water examined by Stephens and Christophers, 15 
presented evidence of malarial infection. The conclusions of the com- 
mittee are worth quoting: 

1. That black-water is malarial in origin, yet can not be considered as 
an attack of malaria. 

2. That quinine is, in a great majority of cases, the proximate cause. 

3. That there is not a single fact in evidence of a special parasite being 
the cause of black-water. 

Malarial Cachexia. — Following constant exposure to malaria and re- 
peated attacks of any one of the forms, there may be a condition charac- 
terized by anaemia with enlarged spleen. 

The general symptoms are those of ordinary anemia — breathlessness 
on exertion, oedema of the ankles, hemorrhages, particularly into the ret- 
ina, as noted by Stephen Mackenzie. Occasionally the bleeding is severe, 
and I have twice known fatal hematemesis to occur in association with 
the enlarged spleen. The fever is variable. The temperature may be low 
for days, not going above 99.5°. In other instances there may be irregular 
fever, and the temperature rises gradually to 102.5° or 103°. The cases 
present a picture of secondary anemia. 

With careful treatment the outlook is good, and a majority of cases 
recover. The spleen is gradually reduced in size, but it may take several 
months or, indeed, in some instances, several years before the ague-cake 
entirely disappears. 

Rarer Complications. — Among nervous sequele and complications 
may be mentioned paraplegia, which may be due to a peripheral neuritis 
or to changes in the cord, and hemiplegia, which may occur in the per- 
nicious comatose form, or occasionally at the very height of a paroxysm. 
Acute ataxia has been described, and there are remarkable cases with the 
symptoms of disseminated sclerosis (Spiller). Multiple gangrene may oc- 
cur, as in an instance recently described by me, in which a patient with 
estivo-autumnal infection presented many areas of multiple gangrene. 
Orchitis has been described as developing in malaria by Charvot in Algiers 
and Fedeli in Rome. 



MALARIAL FEVER. 



217 



Prophylaxis. — In the discovery of Laveran there lay the promise 
of benefits more potent than any gift the laboratory had ever offered 
to mankind — viz., the possibility of the extermination of malaria. By the 
work of Manson, Boss, and others this promise has reached the stage 
of practical fulfilment, and one of the greatest scourges of the race is 
now at our command. The measures of prophylaxis are in the main three: 

(1) The rigid protection of houses against mosquitoes by screens and 
the use of mosquito nets. The accounts of Grassi and Celli of experiments 
made to protect the workers on the railways show how extraordinary 
are the results of these simple measures. The protection of the sleeper 
at night is one of the most essential measures. 

(2) An earnest warfare against the mosquito on the part of sanitary 
authorities. Instruction should be furnished to the people upon the habits 
and life history of the insect, and of its relation to the disease. Pools, 
ponds, and marshy districts should be drained, and in the malaria season 
petroleum should be used freely, as it prevents the development of the 
larvae. Every case of malaria should be regarded as a centre of infection, 
and in a systematic warfare against the disease should be reported to the 
health authorities. In the tropics, segregation of Europeans may do much 
to lessen the chances of infection. 

(3) Lastly, every case should receive thorough and prolonged treatment 
with quinine. There is far too much carelessness on this point in the 
profession. Malarial infection is a difficult one to eradicate. Quinine is 
the only known drug which is an effective parasiticide. Patients should 
be told to resume the treatment in the spring and autumn for several years 
after the primary infection. In very malarial districts, as many persons 
harbor the parasites, who do not show any (or at the most very few) signs, 
a systematic treatment with quinine should be instituted, particularly of 
the young children. 

Diagnosis. — The recognition of the various forms of malarial fever 
is now very easy. The chief difficulty is in the gestivo-autumnal variety 
which may simulate typhoid fever. Practitioners should appreciate the fact 
that in obscure cases a well prepared cover-slip preparation of the blood, 
which can be stained and carefully studied, gives more trustworthy results 
than fresh specimens. To become an expert on the blood in malarial fever 
requires a long and careful training. 

Many forms of intermittent pyrexia are mistaken for malarial fever. In 
instances the blood shows leucocytosis, which is rare in malaria. If 
the practitioner will take to heart the lesson that an intermittent fever 
which resists quinine is not malarial, he will avoid many errors in diag- 
nosis. In the so-called masked intermittent or dumb ague, the febrile 
manifestations are more irregular and the symptoms less pronounced; but 
occasionally chills occur, and the therapeutical test usually removes every 
doubt in the diagnosis. 

The malarial poison is supposed to influence many affections in a re- 
markable way, giving to them a paroxysmal character. A whole series of 
minor ailments and some more severe ones, such as neuralgia, are attrib- 
uted to certain occult effects of paludism. The more closely such cases 
are investigated the less definite appears the connection with malaria. 



•218 



SPECIFIC INFECTIOUS DISEASES. 



Treatment. — We do not know as yet how the poison reaches the sys- 
tem. Infection seems most liable to occnr at night. In regions in which 
the disease prevails extensively mosquito netting should be used, as the 
researches of Eoss render it highly probable that the disease is trans- 
mitted in this way. Persons going to a malarial region should take 
about 10 grains of quinine daily, though Sezary found that 2 grains three 
times a day was a sufficient protection against the disease. During the 
paroxysm the patient should, in the cold stage, be wrapped in blankets and 
given hot drinks. The reactionary fever is rarely dangerous even if it 
reaches a high grade. The body may, however, be sponged. In quinine 
we possess a specific remedy against malarial infection. Experiment has 
shown that the parasites are most easily destroyed by quinine at the stage 
when they are free in the circulation — that is, during and just after sporu- 
lation. While in most instances the parasites of the regularly intermittent 
fevers may be destroyed, even in the intra-corpuscular stage, in aestivo-au- 
tumnal fever this is much more difficult. It should, then, be our object, 
if we wish to most effectually eradicate the infection, to have as much 
quinine in circulation at the time of the paroxysm and shortly before as is 
possible, for this is the period at which sporulation occurs. In the regu- 
larly intermittent fevers from 10 to 30 grains in divided doses throughout 
the day will in many instances prevent any fresh paroxysms. If the patient 
comes under observation shortly before an expected paroxysm, the admin- 
istration of a good dose of quinine just before its onset may be advisable 
to obtain a maximum effect upon that group of parasites. The quinine 
will not prevent the paroxysm, but will destroy the greater part of the 
group of organisms and prevent its further recurrence. It is safer to give 
at least 20 to 30 grains daily for the first three days, and then to continue 
the remedy in smaller doses for the next two or three weeks. In aestivo- 
•■ autumnal fever larger doses may be necessary, though in relatively few in- 
stances is it necessary to give more than 30 to 40 grains in the twenty-four 
hours. 

The quinine should be ordered in solution or in capsules. The pills 
and compressed tablets are more uncertain, as they may not be dissolved. 

A question of interest is the efficient dose of quinine necessary to cure 
the disease. I have a number of charts showing that grain doses three 
times a day will in many cases prevent the paroxysm, but not always with 
the certainty of the larger doses. In cases of sestivo-autumnal fever with 
pernicious symptoms it is necessary to get the system under the influence 
of quinine as rapidly as possible. In these instances the drug should be 
administered hypodermically as the bisulphate in 30-grain doses, with 5 
grains of tartaric acid, every two or three hours. The muriate of quinine 
and urea is also a good form in which to administer the drug hypoder- 
mically; 10, 15, or 20 grain doses may be necessary. In the most severe 
instances some observers advise the intravenous administration of quinine, 
for which the very soluble bimuriate is well adapted. Fifteen grains with 
a grain of sodium chloride may be injected in about 2 drachms of distilled 
water. For extreme restlessness in these cases opium is indicated, and car- 
■diac stimulants, such as alcohol and strychnine, are necessary. If in the 



MALTA FEVER. 



219 



comatose form the internal temperature is raised, the patient should be 
put in a bath and doused with cold water. For malarial anaemia, iron and 
arsenic are indicated. 

An interesting question is much discussed, whether quinine does not 
cause or at any rate aggravate the hemoglobinuria. We have not yet seen 
a case in which this condition has occurred as a result of the use of the 
drug. It seems localized in certain sections; and Bastianelli states that it 
is not seen in the Eoman malarial fevers. He recommends that in any case 
of hemoglobinuria if the blood shows parasites quinine should be admin- 
istered freely. In the post-malarial forms quinine aggravates the attack. In 
an active malarial infection the patient runs less risk with the quinine. 

XXV. MALTA FEVER. 

{Undulant Fever.) 

Definition. — An endemic fever, characterized by an irregular course, 
unclulatory pyrexial relapses, profuse sweats, rheumatic pains, arthritis, 
and an enlarged spleen. An organism, Micrococcus melitensis, is present 
in all cases. 

The greater part of our knowledge of this remarkable disease we owe 
to the work of the army surgeons stationed at Gibraltar and Malta, par- 
ticularly to Marston, to Bruce, and recently to Hughes, whose important 
work on the subject I have used freely for this article. 

Distribution. — The disease prevails extensively at Malta, and is also 
met with in the countries bordering on the Mediterranean; hence the name 
Mediterranean fever. In Gibraltar it is called Eock fever, and in Sicily 
and Italy it is known as Neapolitan fever. It is also met with in India 
and China, and occurs in Porto Rico (Musser and Sailer, W. Cox), and in 
Manila (Strong and Musgrave). Only imported cases have been recognized 
in this country. 

Etiology. — The disease is not contagious. It prevails in summer, and 
in infected regions is endemic, occasionally assuming epidemic characters. 
Insanitary conditions favor its spread, but we can not as yet say whether the 
poison is air-borne or water-borne. Hughes thinks that the former is the 
more probable view, Bruce the latter. Young, healthy adults are chiefly 
attacked. 

Micrococcus melitensis, discovered by Bruce, has not yet been isolated 
from the blood, but occurs in large numbers in the spleen. It is constantly 
present in fatal cases. The morphological and cultural characters have 
been accurately studied by H. E. Durham. The micrococcus is pathogenic 
for monkeys. Four instances of accidental laboratory infection in man 
have been reported, the portal of entry in Strong's case being the con- 
junctiva. 

Symptoms. — There is no specific fever which presents the same re- 
markable group of phenomena. The period of incubation is from six to ten 
days. "Clinically the fever has a peculiarly irregular temperature curve, 
consisting of intermittent waves or undulations of pyrexia, of a distinctly 
remittent character. These pyrexial waves or undulations last, as a rule, 
14 



220 



SPECIFIC INFECTIOUS DISEASES. 



from one to three weeks, with an apyrexial interval, or period of temporary 
abatement of pyrexial intensity between, lasting for two or more days. 
In rare cases the remissions may become so marked as to give an almost 
intermittent character to the febrile curve, clearly distinguishable, how- 
ever, from the paroxysms of paludic infection. This pyrexial condition is 
usually much prolonged, having an uncertain duration, lasting for even 
six months or more. Unlike paludism, its course is not markedly affected 
by the administration of quinine or arsenic. Its course is often irregular 
and even erratic in nature. This pyrexia is usually accompanied by obsti- 
nate constipation, progressive ana?mia, and debility. It is often compli- 
cated with and followed by neuralgic symptoms referred to the peripheral 
or central nervous system, arthritic effusions, painful inflammatory condi- 
tions of certain fibrous structures, of a localized nature, or swelling of the 
testicles " (Hughes). This author recognizes a malignant type, in which 
the disease may prove fatal within a week or ten days; an undulatory type 
— the common variety — in which the fever is marked by intermittent waves 
or undulations of variable length, separated by periods of apyrexia and free- 
dom from symptoms. In this really lie the peculiar features of the dis- 
ease, and the unfortunate victim may suffer a series of relapses which may 
extend from three months, the average time, to two years. Lastly, there 
is an intermittent type, in which the patient may simply have daily pyrexia 
toward evening, without any special complications, and may do well and 
be able to go about his work, and yet at any time the other serious features 
of the disease may develop. 

The mortality is slight, only about 2 per cent. There are no character- 
istic morbid lesions. The seriousness of the disease is in its protracted 
course, so that in the army the loss of time is a very grave item. Malta 
fever has to be distinguished carefully from typhoid fever and from ma- 
laria. From the latter it can be now readily differentiated by the examina- 
tion of the blood. The agglutinative serum reaction is diagnostic. From 
Durham's observations on animals it is probable that the organism may be 
isolated from the urine even after apparent recovery. 

Treatment. — General measures suitable to typhoid fever are indi- 
cated. Fluid food should be given during the febrile period. Hydro- 
therapy, either the bath or the cold pack, should be used every third hour 
when the temperature is above 103° F. Otherwise the treatment is symp- 
tomatic. No drugs appear to have any special influence on the fever. A 
change of climate seems to promote convalescence. 



XXVI. BERI BERI. 

Definition. — An endemic and epidemic multiple neuritis of unknown 
etiology, occurring in tropical and subtropical countries, characterized by 
motor and sensory paralysis and anasarca. 

History. — The disease is believed to be of great antiquity in China, 
arid is possibly mentioned in the oldest known medical treatise. In the 
early years of this century it attracted much attention among the Anglo- 



BEHI-BERI. 



221 



Indian surgeons, and we may date the modern scientific study of the dis- 
ease from Malcolmson's monograph, published in Madras in 1835. The 
opening of Japan gave an opportunity to the German physicians holding 
university positions, particularly Baelz, Scheube, and more recently Grimm, 
to investigate the disease. The studies of the native Japanese physicians, 
particularly Miura and Takagi, and of the Dutch physicians in the East, 
have contributed much to our knowledge. An added interest has been 
given to the subject by the discovery of the disease among the Cape Cod 
fishermen, and by the recurring outbreaks of endemic neuritis at the Rich- 
mond Asylum in Dublin and at the State Insane Hospital at Tuscaloosa, 
Ala. 

Distribution. — Beri-beri, Kakke, or endemic neuritis prevails most 
extensively in the Malay Archipelago; in certain of the Dutch colonies the 
mortality among the coolies is simply frightful. It is widely distributed 
in China, Japan, and the Philippine Islands. In India it has become less 
common, but is still prevalent in parts of Burma. Localized outbreaks 
have occurred in Australia. It prevails extensively in parts of South 
America and in the West Indies, and from the ports of these countries 
cases occasionally reach the United States. Birge, of Provincetown, and J. 
J. Putnam encountered beri-beri among the fishermen on the Newfound- 
land Banks. Birge writes (March 10, 1898) that he has seen 47 cases of 
both the wet and the dry form. The disease is not entirely confined to the 
fishermen on the Grand Banks, but develops occasionally among those liv- 
ing on shore or making " shore trips." In 1895-'96 a remarkable outbreak 
of epidemic neuritis occurred at the State Insane Hospital at Tuscaloosa, 
Ala., which has been described fully by E. D. Bondurant.* Between Feb- 
ruary, 1895, and October, 1896, in a population of 1,200 there were 71 cases 
with 21 deaths. None occurred among the 200 employees of the hospital. 
The negroes were relatively less affected than the whites. The chief symp- 
toms were " muscular weakness, tenderness, pain, paresthesias, loss of deep 
reflexes, followed by atrophy of muscles and the electrical reaction of de- 
generation, accompanied by rise of temperature, gastro-intcstinal disturb- 
ance, general anasarca, and tachycardia." At the Arkansas State Insane 
Asylum at Little Rock, in 1895, there was an outbreak of between 20 and 
30 cases possibly of beri-beri. 

In Great Britain the disease is not infrequent at the seaports. 

At the Richmond Asylum, Dublin, there have been extensive outbreaks 
in the years 1894, 1896, 1897, under conditions of shameful overcrowding. 

Etiology. — Two main views prevail as to the nature of the disease — 
that it is an infection, and that it is a toxaemia caused by food. 

1. Beri-beri as an Acute Infection. — Baelz and Scheube, with many of 
the Dutch physicians, hold that the disease is due to a living germ. In 
favor of this view, Scheube refers to the fact that strong, we 11 -nourished 
young people are attacked, that the disease has definite foci in which it 
prevails, definite seasonal relations, and has of late years spread in some 
countries as an epidemic without any special change in the diet of the 



* New York Medical Journal, 1897, ii. 



222 



SPECIFIC INFECTIOUS DISEASES. 



inhabitants. So far as seasonal and telluric influences are concerned, it is 
a disease which resembles malaria, with which, in fact, some authors 
have confounded it. It is probably not directly contagious. On the other 
hand, Scheube, Manson and others bring forward evidence to show that 
beri-beri may probably be conveyed from one district to another. 
Many bacteriological studies have been made in the disease, particu- 
larly by Dutch physicians, but there is no unanimity as to the results, 
and we may say that no specific organism has as yet been determined 
upon. 

2. The food theory of beri-beri is widely held in Japan, some believing 
that it is due to the eating of bad rice, and others that it is associated with 
the use of certain fish. In favor of the dietetic view of its origin is ad- 
duced the extraordinary change which has taken place in the Japanese 
navy since the introduction by Takagi of an improved diet, allowing a 
larger portion of nitrogenous food, and forbidding the use of fresh fish 
altogether. Subsequent to this there has certainly been the most remark- 
able diminution in the number of cases — a reduction from about a fourth 
of the entire strength attacked annually to a practical abolition of the 
disease. 

A recent number of Janus gives the experience of the Dutch physicians 
in Java, many of whom regard rice as the important cause of the disease. 
It is stated that in the prisons of Java the proportion of cases is 1 to 39 
when the rice is eaten completely shelled, 1 to 10,000 when the grain is 
eaten with its pericarp; in some places the disease has disappeared when 
the unshelled rice has been substituted for the shelled. Miura, with whose 
studies of the disease all readers of Virchow's Archiv are familiar, regards 
beri-beri as a form of chronic poisoning due to the use of the flesh of cer- 
tain fish eaten raw or improperly prepared. Grimm, in his recent mono- 
graph, regards the immunity of Europeans as in great part owing to the 
fact that they do not follow the J apanese custom of eating various kinds of 
raw fish. 

Among the most important factors are the following: Overcrowding, 
as in ships, jails, and asylums, hot and moist seasons, and exposure to wet. 
Europeans under good hygienic conditions rarely contract the disease in 
beri-beri regions. The natives and the imported coolies are the most often 
attacked. Males are more subject to the disease than females. Young men 
from sixteen to twenty-five are most often affected. 

Symptoms. — The incubation period is unknown, but it probably 
extends over several months. The following forms of the disease are recog- 
nized by Scheube: 

1. The incomplete or rudimentary form which often sets in with ca- 
tarrhal symptoms, followed by pains and weakness in the limbs and a lower- 
ing of the sensibility in the legs, with the development of paresthesias. 
Slight oedema sometimes appears. After a time paresthesias may develop 
in other parts of the body, and the patient may complain of palpitation of 
the heart, uneasy sensations in the abdomen, and sometimes shortness of 
breath. There may be weakness and tenderness of the muscles. After 
lasting from a few days to many months, these synrptoms all disappear, but 



BERI-BERI. 



223 



with the return of the warm weather there may be a recurrence. One of 
Scheube's patients suffered in this way for twenty years. 

2. The atrophic form sets in with much the same symptoms, but the 
loss of power in the limbs progresses more rapidly, and very soon the 
patient is no longer able to walk or to move the arms. The atrophy, 
which is associated with a good deal of pain, may extend to the mus- 
cles of the face. The oedematous symptoms and heart troubles play 
a minor role in this form, which is known as the dry or paralytic va- 
riety. 

3. The Wet or Dropsical Form. — Setting in as in the rudimentary vari- 
ety, the oedema soon becomes the most marked feature, extending over 
the whole subcutaneous tissue, and associated with effusions into the serous 
sacs. The atrophy of the muscles and disturbance of sensation are not such 
prominent symptoms. On the other hand, palpitation and rapid action of 
the heart and dyspnoea are common. The wasting may not be apparent 
until the dropsy disappears. 

4. The acute, pernicious, or cardiac form is characterized by threat- 
enings of an acute cardiac failure, developing rapidly after the existence 
of slight symptoms, such as occur in the rudimentary form. In the most 
acute type death may follow within twenty-four hours; more commonly 
the symptoms extend over several weeks. 

The mortality of the disease varies greatly, from 2 or 3 per cent to 40 
or 50 per cent among the coolies in certain of the settlements of the Malay 
Archipelago. 

Morbid Anatomy. — The most constant and striking features are 
changes in the peripheral nerves and degenerative inflammation involving 
the axis cylinder and medullary sheaths. In the acute cases this is found 
not only in the peripheral nerves, but also in the pneumogastric and in 
the phrenic. The fibres of the voluntary muscles, as well as of the myo- 
cardium, are also much degenerated. 

Diagnosis. — In tropical countries there is rarely any difficulty in the 
diagnosis. In cases of peripheral neuritis, associated with oedema, coming 
from tropical ports, the possibility of this disease should be remembered. 
Scheube states that rarely any difficulty offers in the diagnosis of the dif- 
ferent forms. An interesting question arises as to the true nature of the 
endemic neuritis in the Eichmond Asylum and at Tuscaloosa. Bondurant's 
report certainly shows a disease conforming with beri-beri in a majority 
of its features. The statement is made that the Dutch committee which 
studied the epidemic at the Eichmond Asylum did not regard the disease 
as quite identical with the tropical beri-beri. 

Treatment. — Much has been done to prevent the disease, particularly 
in Japan. There is no more remarkable triumph of modern hygiene than 
that which followed Takagi's dietetic reforms in the Japanese navy. In 
beri-beri districts Europeans should use a diet rich in nitrogenous ingredi- 
ents. In the dietary of prisons and asylums the experience of the Javanese 
physicians with reference to the remarkable diminution of the disease with 
the use of unshelled rice should be borne in mind. In ships, prisons, and 
asylums the disease has rarely occurred except in connection with over- 



224 



SPECIFIC INFECTIOUS DISEASES. 



crowding, an element which prevailed both at the Richmond Asylum and 
at the State Hospital for the Insane at Tuscaloosa. 

Baelz recommends in early cases a free use of the salicylates, 15 or 20 
grains four or five times a day. Others favor early free purgation. In 
very severe acute cases, both Anderson and Baelz advise blood-letting. 
The more chronic cases demand, in addition to dietetic measures, drugs to 
support the heart and treatment of the atrophied muscles with electricity 
and massage. 

XXVII. ANTHRAX. 

{Splenic Fever ; Charbon ; Wool-sorter's Disease.) 

Definition. — An acute infectious disease caused by Bacillus anthracis. 
It is a widespread affection in animals, particularly in sheep and cattle. 
In man it occurs sporadically or as a result of accidental inoculations with 
the virus. 

Etiology. — The infectious agent is a non-motile, rod-shaped organ- 
ism, Bacillus atithracis, which has, by the researches of Pollender, Da- 
vaine, Koch, and Pasteur, become the best known perhaps of all patho- 
genic microbes. The bacillus has a length of from 2 to 25 /a; the rods are 
often united. They multiply by fission with great rapidity and are easily 
grown on various culture media, extending into long filaments which in- 
terlace and produce a dense network. The spore formation is seen with 
great readiness in these filaments; but an asporogenous variety is known, 
and can be produced artificially in cultures. The bacilli themselves are 
readily destroyed, but the spores are very resistant, and survive after pro- 
longed immersion in a 5-per-cent solution of carbolic acid, or withstand 
for some minutes a temperature of 212° Fahr. They are capable also of re- 
sisting gastric digestion. Outside the body the spores are in all probability 
very durable. 

Geographically and zoologically the disease is the most widespread of 
all infectious disorders. It is much more prevalent in Europe and in Asia 
than in America. Its ravages among the herds of cattle in Russia and 
Siberia, and among sheep in certain parts of Europe, are not equalled by 
any other animal plague. In this country the disease is rare. A few pas- 
tures in Delaware and Pennsylvania have recently become infected, prob- 
ably from imported hides. Human infections are chiefly in tanners, of 
whom 12 died in the State of Pennsylvania of anthrax in 1897 (Ravenel). 
So far as I know, it has never prevailed on the ranches in the Northwest, 
but cases were not infrequent about Montreal. 

A protective inoculation with a mitigated virus was introduced by 
Pasteur, and has been adopted in certain anthrax regions. 

In animals the disease is conveyed sometimes by direct inoculation, as 
by the bites and stings of insects, by feeding on carcasses of animals which 
have died of the disease, but more commonly by grazing in pastures in 
which the germs have been preserved. Pasteur believes that the earth- 
worm plays an important part in bringing to the surface and distributing 
the bacilli which have been propagated in the buried carcass of an in- 
fected animal. Certain fields, or even farms, may thus be infected for an 



ANTHRAX. 



225 



indefinite period of time. It seems probable, however, that if the carcass 
is not opened or the blood spilt, spores are not formed in the bnried ani- 
mal and the bacilli quickly die. 

Animals vary in susceptibility: the herbivora come first, then the om- 
nivora, and lastly the carnivora. The disease does not occur spontane- 
ously in man, but always results from infection, either through the skin, 
the intestines, or in rare instances through the lungs. It is found in per- 
sons whose occupations bring them into contact with animals or animal 
products, as stablemen, shepherds, tanners, butchers, and those who work 
in wool and hair. 

Various forms of the disease have been described, and two chief groups 
may be recognized: the external anthrax and the internal anthrax, of which 
there are pulmonary and intestinal forms. 

Symptoms.— (1) External Anthrax. 

(a) Malignant Pustule. — The inoculation is usually on an exposed sur- 
face — the hands, arms, or face. At the site of inoculation there are, within 
a few hours, itching and uneasiness. Gradually a small papule develops, 
which becomes vesicular. Inflammatory induration extends around this, 
and within thirty-six hours, at the site of inoculation there is a dark brown- 
ish eschar, at a little distance from which there may be a series of small 
vesicles. The brawny induration may be extreme. The oedema produces 
very great swelling of the parts. The inflammation extends along the lym- 
phatics, and the neighboring lymph-glands are swollen and sore. The 
fever at first rises rapidly, and the concomitant phenomena are marked. 
Subsequently the temperature falls, and in many cases becomes subnormal. 
Death may take place in from three to five days. In cases which recover 
the constitutional symptoms are slighter, the eschar gradually sloughs out, 
and the wound heals. The cases vary much in severity. In the mildest 
form' there may be only slight swelling. At the site of inoculation a papule 
is formed, which rapidly becomes vesicular and dries into a scab, which 
separates in the course of a few days. 

(h) Malignant Anthrax (Edema. — This form occurs in the eyelid, and 
also in the head, hand, and arm, and is characterized by the absence of the 
papule and vesicle forms, and by the most extensive oedema, which may 
follow rather than precede the constitutional symptoms. The oedema 
reaches such a grade of intensity that gangrene results, and may involve a 
considerable -nrface. The constitutional symptoms then become extremely 
grave, and the cases invariably prove fatal. 

The greatest fatality is seen in cases of inoculation about the head and 
face, where the mortality, according to Nasarow, is 20 per cent; the least 
in infection of the lower extremities, where it is 5 per cent. 

Tn a recent case, in a hair-picker, there was most extensive enteritis, 
peritonitis, and endocarditis, which last lesion has been described by 
Eppinger. 

A feature in both these forms of malignant pustule, to which many 
writers refer, is the absence of feeling of distress or anxiety on the part of 
the patient, whose mental condition may be perfectly clear. ITe may be 
without any apprehension, even though his condition is very critical. 



226 



SPECIFIC INFECTIOUS DISEASES. 



The diagnosis in most instances is readily made from the character of 
the lesion and the occupation of the patient. When in doubt, the exami- 
nation of the fluid from the pustule may show the presence of the anthrax 
bacilli. Cultures should be made, or a mouse or guinea-pig inoculated 
from the local lesion. It is to be remembered that the blood may not show 
the bacilli in numbers until shortly before death. 

(2) Internal Anthrax. 

(a) Intestinal Form, Mycosis intestinalis. — In these cases the infection 
usually is through the stomach and intestines, and results from eating the 
flesh or drinking the milk of diseased animals; it may, however, follow an 
external infection if the germs are carried to the mouth. The symptoms 
are those of intense poisoning. The disease may set in with a chill, fol- 
lowed by vomiting, diarrhoea, moderate fever, and pains in the legs and 
back. In acute cases there are dyspnoea, cyanosis, great anxiety and rest- 
lessness, and toward the end convulsions or spasms of the muscles. Hem- 
orrhage may occur from the mucous membranes. Occasionally there are 
small phlegmonous areas on the skin, or petechiae develop. The spleen is 
enlarged. The blood is dark and remains fluid for a long time after death. 
Late in the disease the bacilli may be found in the blood. 

This is one of the forms of acute poisoning which may affect many in- 
dividuals together. Thus Butler and Karl Huber describe an epidemic 
in which twenty-five persons were attacked after eating the flesh of an 
animal which had had anthrax. Six died in from forty-eight hours to 
seven days. 

(b) Wool-sorter's Disease. — This important form of anthrax is found 
in the large establishments in which wool or hair is sorted and cleansed. 
The hair and wool imported into Europe from Eussia and South America 
appear to have induced the largest number of cases. Many of these show 
no external lesion. The infective material has been swallowed or inhaled 
with the dust. There are rarely premonitory symptoms. The patient is 
seized with a chill, becomes faint and prostrated, has pains in the back 
and legs, and the temperature rises to 102° or 103°. The breathing is 
rapid, and he complains of much pain in the chest. There may be a cough 
and signs of bronchitis. So prominent in some instances are these bron- 
chial symptoms that a pulmonary form of the disease has been described. 
The pulse is feeble and very rapid. There may be vomiting, and death 
may occur within twenty-four hours with symptoms of profound collapse 
and prostration. Other cases are more protracted, and there may be diar- 
rhoea, delirium, and unconsciousness. The cerebral symptoms may be 
most intense; in at least four cases the brain seems to have been chiefly 
affected, and its capillaries stuffed with bacilli (Merkel). The recognition 
of wool-sorter's disease as a form of anthrax is due to J. H. Bell, of Brad- 
ford, England. 

In certain instances these profound constitutional symptoms of internal 
anthrax are associated with the external lesions of malignant pustule. 

The rag-picker's disease has been made the subject of an exhaustive 
study by Eppinger (Die Hadernkrankheit, Jena, 1894), who has shown that 
it is a local anthrax of the lungs and pleura, with general infection. 



HYDROPHOBIA. 



227 



The diagnosis of internal anthrax is by no means easy, unless the his- 
tory points definitely to infection in the occupation of the individual. 

Treatment. — In malignant pustule the site of inoculation should be 
destroyed by the caustic or hot iron, and powdered bichloride of mercury 
may be sprinkled over the exposed surface. The local development of the 
bacilli about the site of inoculation may be prevented by the subcutaneous 
injections of solutions of carbolic acid or bichloride of mercury. The 
injections should be made at various points around the pustule, and may 
be repeated two or three times a day. The internal treatment, should be 
confined to the administration of stimulants and plenty of nutritious food. 
Davies-Colley advises ipecacuanha powder in doses of from 5 to 10 grains 
every three or four hours. 

In malignant forms, particularly the intestinal cases, little can be clone. 
Active purgatives may be given at the outset, so as to remove the infect- 
ing material. Quinine in large doses has been recommended. 

XXVIII. HYDROPHOBIA. 

{Lyssa ; Rabies) 

Definition. — An acute disease of warm-blooded animals, dependent 
upon a specific virus, and communicated by inoculation to man. 

Etiology. — Kabies is very variously distributed. In Russia it is com- 
mon. In North Germany it is relatively rare, owing to the wise provision 
that all dogs shall be muzzled; in England and France it is much more com- 
mon. In this country the disease occurs more often than is generally sup- 
posed, as is shown by the number of authentic cases collected by Salmon 
[Yearbook of the United States Department of Agriculture, p. 210, 1901]. 

Canines are specially liable to the disease. It is found most frequently 
in the dog, the wolf, the cat, and the cow. Most animals are, however, sus- 
ceptible; and it is communicable by inoculation to the rabbit, horse, or pig. 
The disease is propagated chiefly by the dog, which seems specially suscep- 
tible. In the Western States the skunk is said to be very liable to the dis- 
ease. The nature of the poison is as yet unknown. It is contained chiefly 
in the nervous system and is met with in some of the secretions, particularly 
in the saliva. 

A variable time elapses between the introduction of the virus and the 
appearance of the symptoms. Horsley states that this depends upon the 
following factors: " (a) Age. The incubation is shorter in children than 
in adults. For obvious reasons the former are more frequently attacked. 
(b) Part infected. The rapidity of onset of the symptoms is greatly de- 
termined by the part of the body which may happen to have been bitten. 
Wounds about the face and head are especially dangerous; next in order 
in degrees of mortality come bites on the hands, then injuries on the other 
parts of the body. This relative order is, no doubt, greatly dependent 
upon the fact that the face, head, and hands are usually naked, while the 
other parts arc clothed; it would also appear to depend somewhat upon 
the richness in nerves of the part, (c) The extent and severity of the 



228 



SPECIFIC INFECTIOUS DISEASES. 



wound. Puncture wounds are the most dangerous; the lacerations are 
fatal in proportion to the extent of the surface afforded for absorption of 
the virus, (d) The animal conveying the infection. In order of decreas- 
ing severity come: first, the wolf; second, the cat; third, the dog; and 
fourth, other animals." Only a limited number of those bitten by rabid 
dogs become affected by the disease; according to Horsley, not more than 
15 per cent. On the other hand, the death-rate of those persons bitten by 
wolves is higher, not less than 40 per cent. Babes gives the mortality as 
from 60 to 80 per cent. 

The incubation period in man is extremely variable. The average is 
from six weeks to two months. In a few cases it has been under two weeks. 
It may be prolonged to three months. It is stated that the incubation 
may be prolonged for a year or even two years, but this has not been defi- 
nitely settled. 

Symptoms. — Three stages of the disease are recognized: 

(1) Premonitory stage, in which there may be irritation about the bite, 
pain, or numbness. The patient is depressed and melancholy; and com- 
plains of headache and loss of appetite. He is very irritable and sleepless, 
and has a constant sense of impending danger. There is often greatly 
increased sensibility. A bright light or a loud voice is distressing. The 
larynx may be injected and the first symptoms of difficulty in swallowing 
are experienced. The voice also becomes husky. There is a slight rise in 
the temperature and the pulse. 

(2) Stage of Excitement. — This is characterized by great excitability 
and restlessness, and an extreme degree of hyperesthesia, " Any afferent 
stimulant — i. e., a sound or a draught of air, or the mere association of 
a verbal suggestion — will cause a violent reflex spasm. In man this symp- 
tom constitutes the most distressing feature of the malady. The spasms, 
which affect particularly the muscles of the larynx and mouth, are exceed- 
ingly painful and are accompanied by an intense sense of dyspnoea, even 
when the glottis is widely opened or tracheotomy has been performed 99 
(Horsley). Any attempt to take water is followed by an intensely painful 
spasm of the muscles of the larynx and of the elevators of the hyoid bone. 
It is this which makes the patient dread the very sight of water and gives 
the name hydrophobia to the disease. These spasmodic attacks may be 
associated with maniacal symptoms. In the intervals between them the 
patient is quiet and the mind unclouded. The temperature in this stage 
is usually elevated and may reach from 100° to 103°. In some instances the 
disease is afebrile. The patient rarely attempts to injure his attendants, 
and in the intense spasms may be particularly anxious to avoid hurting 
any one. There are, however, occasional fits of furious mania, and the 
patient may, in the contractions of the muscles of the larynx and pharynx, 
give utterance to odd sounds. This stage lasts from a day and a half to 
three days and gradually passes into the — 

(3) Paralytic Stage. — In rodents the preliminary and furious stages 
are absent, as a rule, and the paralytic stage may be marked from the out- 
set — the so-called dumb rabies. This stage rarely lasts longer than from 
six to eighteen hours. The patient then becomes quiet; the spasms no 



HYDROPHOBIA. 



229 



longer occur; unconsciousness gradually supervenes; the heart's action be- 
comes more and more enfeebled, and death occurs by syncope. 

Morbid Anatomy. — The important lesions consist in the accumula- 
tion of leucocytes around the blood-vessels and the nerve-cells, particularly 
the motor ganglion cells, of the central nervous system (rabic tubercles of 
Babes). Especial importance in the rapid diagnosis of rabies is attached 
by van Gehuchten and Nelis to the accumulation of lymphoid and endothe- 
lioid cells around nerve-cells of the sympathetic and cerebro-spinal ganglia. 
Various degenerations of nerve-cells occur. The inoculation experiments 
show that the virus is not present in the liver, spleen, or kidneys, but is 
abundant in the spinal cord, brain, and peripheral nerves. 

Treatment. — Prophylaxis is of the greatest importance, and by a 
systematic muzzling of dogs the disease can be, as in parts of Germany, 
practically eradicated. 

The bites should be carefully washed and thoroughly cauterized with 
caustic potash or concentrated carbolic acid. It is best to keep the wound 
constantly open for at least five or six weeks. When once established the 
disease is hopelessly incurable. No measures have been found of the slight- 
est avail, consequently the treatment must be palliative. The patient 
should be kept in a darkened room, in charge of not more than two care- 
ful attendants. To allay the spasm, chloroform may be administered and 
morphia given hypodermically. It is best to use these powerful remedies 
from the outset, and not to temporize with chloral, bromide of potassium, 
and other less potent drugs. By the local application of cocaine, the sensi- 
tiveness of the throat may be diminished sufficiently to enable the patient 
to take liquid nourishment. Sometimes he can swallow readily. Nutrient 
enemata should be administered. 

Preventive Inoculation. — Pasteur has found that the virus, when propa- 
gated through a series of rabbits, increases in its virulence; so that whereas 
subdural inoculation from the brain of a mad clog takes from fifteen to 
twenty days to produce the disease, in successive inoculation in a series of 
rabbits the incubation period is gradually reduced to seven days (virus fixe). 
The spinal cords of these rabbits contain the virus in great intensity, but 
when they are preserved in dry air this gradually diminishes. If now dogs 
are inoculated from cords preserved for from twelve to fifteen days, and 
then from cords preserved for a shorter period, i. e., with a progressively 
stronger virus, they gradually acquire immunity against the disease. A 
dog treated in this way will resist inoculation with the vims fixe, which 
otherwise would inevitably have proved fatal. Eelying upon these experi- 
ments, Pasteur began inoculations in the human subject, using, on succes- 
sive days, material from cords in which the virus was of varying degrees 
of intensity. 

The statistics published annually from the Pasteur Institute and else- 
where prove exclusively the importance of this method as a protective 
measure in man. The figures given by Pottevin, being the cases treated 
in Paris from 1886 to 1894 inclusive, show that of 13,817 persons bitten 
the mortality was 0.5 per cent Of these, 1,3-17 were bitten on the head, 



230 



SPECIFIC INFECTIOUS DISEASES. 



the mortality being 1.26 per cent; 8,722 on the hands, with 0.T6 per cent of 
deaths; and 5,746 on other parts of the body, with a mortality of 0.28 per 
cent. 

Diagnosis. — After the symptoms of the disease have developed in 
man the diagnosis should offer no especial difficulties. It is advisable, in 
cases attended with any doubts, as soon as possible after the injury has been 
inflicted, to secure the medulla oblongata of the supposed rabid animal for 
the purpose of inoculating rabbits. The subdural inoculation of rabbits 
with a small quantity of the central nervous system of a rabid animal will 
be followed by the development of the paralytic form of the disease in from 
fifteen to twenty days. 

Pseudo-hydrophobia (Lyssophobia). — This is a very interesting 
affection, which may closely resemble hydrophobia, but is really nothing 
more than a neurotic or hysterical manifestation. A nervous person bitten 
by a dog, either rabid or supposed to be rabid, develops within a few months, 
or even later, symptoms somewhat resembling the true disease. He is irri- 
table and depressed. He constantly declares his condition to be serious 
and that he will inevitably become mad. He may have paroxysms in which 
he says he is unable to drink, grasps at his throat, and becomes emotional. 
The temperature is not elevated and the disease does not progress. It lasts 
much longer than the true rabies, and is amenable to treatment. It is not 
improbable that a majority of the cases of alleged recovery in this disease 
have been of this hysterical form. In a case which Burr reported from 
my clinic a few years ago the patient had paroxysmal attacks in which he 
could not swallow. He was greatly excited and alarmed at the sight of 
water and was extremely emotional. The symptoms lasted for a couple of 
weeks and yielded to treatment with powerful electrical currents. 

XXIX. TETANUS. 

(Lockjaw.) 

Definition. — An infectious malad} T characterized by tonic spasms of 
the muscles with marked exacerbations. The virus is produced by a 
bacillus which occurs in earth and sometimes in putrefying fluids and 
manure. 

Etiology. — It occurs as an idiopathic affection or follows trauma. It 
is frequent in some localities and has prevailed extensively in epidemic 
form among new-born children, when it is known as tetanus or trismus 
neonatorum. It is more common in hot than in temperate climates, and 
in the colored than in the Caucasian race. This is particularly the case 
with tetanus following confinement and in tetanus neonatorum. In cer- 
tain of the West Indian Islands more than one half of the mortality among 
the negro children has been due to this cause. St. Kilda. one of the west- 
ern Hebrides, had been scourged for years by the " eight days' sickness 73 
among the new-born. Of 125 children, 84 died within fourteen days of 
birth. Since the discovery of the tetanus bacillus, some philanthropic peo- 
ple in Glasgow sent a nurse to the island, who taught the midwives to use 



TETANUS. 



231 



iodoform on the navel. The disease has now practically disappeared 
(Turner). In a majority of the cases there is an injury which may be of 
the most trifling character. It is more common after punctured and con- 
tused than after incised wounds, and frequently follows those of the hands 
and feet. The symptoms usually appear within two weeks of the injury. In 
some military campaigns tetanus has prevailed extensively, but in others, 
as in the late civil war, the cases have been comparatively few. Idiopathic 
tetanus is rare in man, but it has sometimes followed exposure to cold or 
sleeping on the damp ground. The disease has occurred after prolonged 
use of the hypodermic needle for morphia and quinine injections. 

The infectious nature of tetanus was suggested by its endemic occur- 
rence and from the manner of its behavior in certain institutions. Vet- 
erinarians have long been of this belief, as cases are apt to occur together 
in horses in one stable. On the eastern end of Long Island, where formerly 
the disease was very prevalent, it is now rarely seen. 

The Tetanus Bacillus. — The observations of Eosenbach, Nicolaier, and 
Kitasato have demonstrated that there is in connection with the disease a 
specific organism which can be isolated and cultivated. Bacillus tetani is 
a slender rod, which may grow into long threads. One end is often swollen 
and occupied by a spore. It is motile, grows at ordinary temperatures, and 
is anaerobic. The bacilli develop at the site of the wound (and do not in- 
vade the blood and organs), where alone the toxine is manufactured. With 
small quantities of the culture the disease may be transmitted to animals, 
which die with symptoms of tetanus. The poison is a tox-albumin of 
extraordinary potency, which has been separated by Brieger and Cohn 
in a state of tolerable purity. It is perhaps the most virulent poison known. 
Whereas the fatal dose of strychnine for a man weighing 70 kilos is from 
30 to 100 milligrammes, that of the tetanus toxine is estimated at 0.23 
milligramme. Every feature of the disease can be produced by it experi- 
mentally without the presence of the bacilli. The symptoms do not develop 
immediately, as in the case of ordinary poisons, but slowly, and it has been 
suggested that it acts only after undergoing some further change in the 
body. The natural home of the tetanus bacillus is the soil and the in- 
testinal canal of herbivorous animals. The disease can be produced by 
inoculating animals with garden earth. A high degree of antitoxic im- 
munity can be conferred on animals, which then yield a protective serum. 
It is, however, difficult to cure animals with this serum on account of 
the combination of the toxine with nerve-cells by the time symptoms 
appear. 

Morbid Anatomy. — No characteristic lesions have been found in 
the cord or in the brain. Congestions occur in different parts, and peri- 
vascular exudations and granular changes in the nerve-cells have been 
found. The condition of the wound is variable. The nerves are often 
found injured, reddened, and swollen. In the tetanus neonatorum the um- 
bilicus may be inflamed. 

Symptoms. — After an injury the disease sets in usually within ten 
days. In Yandell's statistics in at least two fifths, and in Joseph Jones's 



232 



SPECIFIC INFECTIOUS DISEASES. 



in four fifths, the symptoms occurred before the fifteenth day. The pa- 
tient complains at first of slight stiffness in the neck, or a feeling of tight- 
ness in the jaws, or difficulty in mastication. Occasionally chilly feelings 
or actual rigors may precede these symptoms. Gradually a tonic spasm 
of the muscles of these parts develops, producing the condition of trismus 
or lockjaw. The eyebrows may be raised and the angles of the mouth 
drawn out, causing the so-called sardonic grin — risus sardonicus. In chil- 
dren the spasm may be confined to these parts. Sometimes the attack 
is associated with paralysis of the facial muscles and difficulty in swallow- 
ing — the head-tetanus of Eose, which has most commonly followed injuries 
in the neighborhood of the fifth nerve. Gradually the process extends 
and involves the muscles of the body. Those of the back are most affected, 
so that during the spasm the unfortunate victim may rest upon the head 
and heels — a position known as opisthotonos. The rectus abdominalis mus- 
cle has been torn across in the spasm. The entire trunk and limbs may 
be perfectly rigid — orthotonus. Flexion to one side is less common — pleuro- 
thotonos; while spasm of the muscles of the abdomen may cause the body 
to be bent forward — emprosthotonos. In very violent attacks the thorax is 
compressed, the respirations are rapid, and spasm of the glottis may occur, 
causing asphyxia. The paroxysms last for a variable period, but even in 
the intervals the relaxation is not complete. The slightest irritation is 
sufficient to cause a spasm. The paroxysms are associated with agonizing 
pain, and the patient may be held as in a vice, unable to utter a word. 
Usually he is bathed in a profuse ^weat. The temperature may remain 
normal throughout, or show only a slight elevation toward the close. In 
other cases the pyrexia is marked from the outset; the temperature reaches 
105° or 106°, and before death 109° or 110°. In rare instances it may go 
still higher. Death either occurs during the paroxysm from heart-failure 
or asphyxia, or is due to exhaustion. 

The cephalic tetanus (Kopf tetanus of Eose) originates usually from a 
wound on one side of the head, and is characterized by stiffness of the 
muscles of the jaw and paralysis. of the facial muscles on the same side as 
the wound, with difficulty in swallowing. 

The prognosis is good in the chronic cases; of these, in Willard's table 
only 8 of 32 died; but in the acute form, of 45 cases, only 4 recovered. 

Diagnosis. — Well-developed cases following a trauma could not be 
mistaken for any other disease. The spasms are not unlike those of 
strychnia-poisoning, and in the celebrated Palmer murder trial this was 
the plea for the defence. The jaw-muscles, however, are never involved 
early, if at all, and between the paroxysms in strychnia-poisoning there 
is no rigidity. In tetany the distribution of the spasm at the extremities, 
the peculiar position, the greater involvement of the hands, and the con- 
dition under which it occurs, are sufficient to make the diagnosis clear. In 
doubtful cases cultures should be made from the pus of the wound. 

Prognosis. — Two of the Hippocratic aphorisms express tersely the 
general prognosis even at the present day: " The spasm supervening on a 
wound is fatal/' and " such persons as are seized with tetanus die within 
four days, or if they pass these they recover." 



GLANDERS. 



233 



The mortality in the traumatic cases is not less than 80 per cent (Con- 
ner); in the idiopathic cases it is under 50 per cent. According to Yandell, 
the mortality is greatest in children. Favorable indications are: late onset 
of the attack, localization of the spasms to the muscles of the neck and jaw, 
and an absence of fever. 

Treatment. — Local treatment of the wound is essential, as the poison 
is manufactured here. Tizzoni advises nitrate of silver as the best germi- 
cide for the tetanus bacillus. Thorough excision and antiseptic treatment 
should be carried out. The patient should be kept in a darkened room, 
absolutely quiet, and attended by only one person. All possible sources 
of irritation should be avoided. Veterinarians appreciate the importance 
of this complete seclusion, and in well-equipped infirmaries there may be 
seen a brick padded chamber in which the horses are treated. 

When the lockjaw is extreme the patient may not be able to take food 
by the mouth, under which circumstances it is best to use rectal injections, 
or to feed by a catheter passed through the nose. The spasm should be 
controlled by chloroform, which may be repeatedly exhibited at intervals. 
It is more satisfactory to keep the patient thoroughly under the influence 
of morphia given hypodermically. Chloral hydrate, bromide of potassium, 
Calabar bean, curara, Indian hemp, belladonna, and other drugs have been 
recommended, and recovery occasionally follows their use. It is very diffi- 
cult to estimate the value of the blood-serum therapy in this disease. Al- 
though tetanus antitoxine of great strength can be obtained, its use in the 
treatment of human tetanus has been disappointing. The best results are 
obtained in the subacute cases, but here the prognosis is relatively favor- 
able even with other methods of treatment. There may be occasion for the 
prophylactic use of the antitoxine in man, as already successfully practised 
in arresting the spread of the disease in horses occupying infected stables. 
Of the antitoxic serum 20 to 30 cc. may be used for the first dose and 15 
to 20 cc. every five or ten hours after. Tizzoni advises 2.25 grammes of 
his antitoxine for the first dose and 0.6 grammes for subsequent doses. 



XXX. GLANDERS (Farcy). 

Definition. — An infectious disease of the horse, communicated occa- 
sionally to man. In the horse it is characterized by the formation of 
nodules, chiefly in the nares (glanders) and beneath the skin (farcy). 

Etiology. — The disease belongs to the infective granulomata. The 
local manifestations in the nostrils and the skin of the horse are due to 
one and the same cause. The specific germ, Bacillus mallei, was discovered 
by Loeffler and Schutz. It is a short, non-motile bacillus, not unlike that 
of tubercle, but exhibits different staining reactions. It grows readily on 
the ordinary culture media. For the full recognition of glanders in man 
we are indebted to the labors of Rayer, whose monograph remains one of 
the best descriptions ever given of the disease. Man becomes infected by 
contact with diseased animals, and usually by inoculation on an abraded 



23± 



SPECIFIC INFECTIOUS DISEASES. 



surface of the skin. The contagion may also be received on the mucous 
membrane. In one of the Montreal cases a gentleman was probably in- 
fected by the material expelled from the nostril of his horse, which was 
not suspected of having the disease. 

Morbid Anatomy. — As in the horse, the disease may be localized 
in the nose (glanders) or beneath the skin (farcy). The essential lesion 
is the granulomatous tumor, characterized by the presence of numerous 
lymphoid and epithelioid cells, among and in which are seen the glanders 
bacilli. These nodular masses tend to break down rapidly, and on the 
mucous membrane result in ulcers, while beneath the skin they form ab- 
scesses. The glanders nodules may also occur in the internal organs. 

Symptoms. — An acute and a chronic form of glanders may be recog- 
nized in man, and an acute and a chronic form of farcy. 

Acute Glanders. — The period of incubation is rarely more than three 
or four days. There are signs of general febrile disturbance. At the site 
of infection there are swelling, redness, and lymphangitis. Within two or 
three days there is involvement of the mucous membrane of the nose, the 
nodules break down rapidly to ulcers, and there is a muco-purulent dis- 
charge. An eruption of papules, which rapidly become pustules, breaks 
out over the face and about the joints. It has been mistaken for variola. 
This was carefully studied by Eayer and is figured in his monograph. In 
a Montreal case this copious eruption led the attending physician to sus- 
pect small-pox, and the patient was isolated. There is great swelling of 
the nose. The ulceration may go on to necrosis, in which case the discharge 
is very offensive. The lymph-glands of the neck are usually much en- 
larged. Subacute pneumonia is very apt to develop. This form runs its 
course in about eight or ten days, and is invariably fatal. 

Chronic glanders is rare and difficult to diagnose, as it is usually mis- 
taken for a chronic coryza. There are ulcers in the nose, and often laryn- 
geal symptoms. It may last for months, or even longer, and recovery some- 
times takes place. Tedeschi has described a case of chronic osteomyelitis, 
due to the bacillus mallei, which was followed by a fatal glanders menin- 
gitis. The diagnosis may be extremely difficult. In such cases a suspen- 
sion of the secretion, or of cultures upon agar-agar made from the secre- 
tion, should be injected into the peritoneal cavity of a male guinea-pig. 
At the end of two days, in positive cases, the testicles are found to be 
swollen and the skin of the scrotum reddened. The testicles continue to 
increase in size, and finally suppurate. Death takes place after the lapse 
of two or three weeks, and generalized glanders nodules are found in the 
viscera. The use of mallein for diagnostic purposes is highly recommended. 
The principles and methods of application are the same as for tuberculin. 

Acute farcy in man results usually from the inoculation of the virus 
into the skin. There is an intense local reaction with a phlegmonous in- 
flammation. The lymphatics are early affected, and along their course 
there are nodular subcutaneous enlargements, the so-called farcy buds, 
which may rapidly go on to suppuration. There are pains and swelling 
in the joints and abscesses may form in the muscles. The symptoms are 
those of an acute infection, almost like an acute septicaemia. The nose is 



ACTINOMYCOSIS. 



235 



not involved and the superficial skin eruption is not common. The bacilli 
have been found in the urine in acute cases in man and animals. 

The disease is fatal in a large proportion of the cases, usually in from 
twelve to fifteen days. 

Chronic farcy is characterized by the presence of localized tumors, usu- 
ally in the extremities. These tumors break down into abscesses, and some- 
times form deep ulcers, without much inflammatory reaction and without 
special involvement of the lymphatics. The disease may last for months 
or even years. Death may result from pyaemia, or occasionally acute glan- 
ders develops. The celebrated French veterinarian Bouley had it and re- 
covered. 

The disease is transmissible also from man to man. Washerwomen 
have been infected from the clothes of a patient. In the diagnosis of this 
affection the occupation is very important. Nowadays, in cases of doubt, 
the inoculation should be made in animals, as in this way the disease can 
be readily determined. Mallein, a product of the growth of the bacilli, is 
now used for the purpose of diagnosing glanders in animals. Several in- 
stances of cured glanders have been reported in animals treated with small 
and repeated doses of mallein (Pilavios, Babes). 

Treatment. — If seen early, the wound should be either cut out or 
thoroughly destroyed by caustics and an antiseptic dressing applied. The 
farcy buds should be early opened. In the acute cases there is very little 
hope. In the chronic cases recovery is possible, though often tedious. 



XXXI. ACTINOMYCOSIS. 

Definition. — A chronic infective disorder produced by the actino- 
myces or ray-fungus, Streptothrix actinomyces. 

Etiology. — The disease is widespread among cattle, and occurs also 
in the pig. It was first* described by Bollinger in the ox, in which it forms 
the affection known in this country as " big-jaw." Examples of the dis- 
ease were common in the cattle killed at the abattoir in Montreal. In man 
it was mentioned by von Langenbeck, who observed the " sulphur grains " 
in the characteristic purulent material. The first accurate description of 
the disease was given by James Israel, and subsequently Ponfick insisted 
upon the identity of the disease in man and cattle. 

In this country to May 1, 1898, about 41 cases have been recognized 
(Ruhrah); in England the disease is rare. It is not uncommon in Ger- 
many and Russia. To the end of 1892 about 450 cases had been described 
(Leith, Edinburgh Hospital Reports, vol. ii). It is nearly three times as 
common in men as in women. 

The parasite belongs probably to the Streptothrix group of bacteria. 
In both man and cattle it can be seen in the pus from the affected region 
as yellowish or opaque granules from one half to two millimetres in diam- 
eter, which are made up of cocci and radiating threads, which present 
bulbous, club-like terminations. The youngest granules are gray in color 
and semi-translucent; in these the bulbous extremities are wanting. It 
15 



236 



SPECIFIC INFECTIOUS DISEASES. 



was shown "by Bostrom that the clubhed ends are the result of a hyaline, 
degenerative change taking place in the sheaths of the filaments. The 
organism is strikingly pleomorphic. 

The parasite has been successfully cultivated, and the disease has been 
inoculated both with the natural and artificially grown organism. 

The Mode of Infection. — There is no evidence of direct infection with the 
flesh or milk of diseased animals. The streptothrix has not been detected 
outside the body. It seems highly probable that it is taken in with the 
food. The site of infection in a majority of cases in man and animals is 
in the mouth or neighboring passages. In the cow, possibly also in man, 
barley, oats, and rye have been carriers of the germ. 

Morbid Anatomy. — In the earliest stages of its growth the para- 
site gives rise to a small granulation tumor not unlike that produced by 
Bacillus tuberculosis, which contains, in addition to small round cells, 
epithelioid elements and giant cells. After it reaches a certain size there 
is great proliferation of the surrounding connective tissue, and the growth 
may, particularly in the jaw, look like, and was long mistaken for, osteo- 
sarcoma. Finally suppuration occurs, which in man, according to Israel, 
may be produced directly by the streptothrix itself. 

" Clinical Forms. — (a) Alimentary Canal. — Israel is said to have 
found the fungus in the cavities of carious teeth. The jaw has been af- 
fected in a number of cases in man. The patient comes under observation 
with swelling of one side of the face, or with a chronic enlargement of the 
jaw which may simulate sarcoma. 

The tongue has been involved in several cases, showing small growths, 
either primary or following disease of the jaw. In the intestines the disease 
may occur either as a primary or secondary affection. Cases have been 
reported of pericecal abscess due to the germ. An actinomycotic appen- 
dicitis has been described; primary actinomycosis of the large intestine 
with metastases has also been described. Eansom has found the actinomyces 
in the stools. The liver may be affected primarily, as in the case reported 
by Sharkey and Acland. The actinomycotic abscesses present a reticular 
or honeycomb-like arrangement (Leith). 

(b) Pulmonary Actinomycosis. — In September, 1878, James Israel de- 
scribed a remarkable mycotic disease of the lungs, which subsequent ob- 
servation showed to be the affection described the year before by Bollinger 
in cattle. Since that date many instances have been reported in which 
the lungs were affected. It is a chronic infectious pulmonary disorder, 
characterized by cough, fever, wasting, and a muco-purulent, sometimes 
foetid, expectoration. The lesions are unilateral in a majority of the cases. 
Hodenpyl classifies them in three groups: (1) Lesions of chronic bron- 
chitis; the diagnosis has been made by the presence of the actinomyces 
in the sputum. (2) Miliary actinomycosis, closely resembling miliary tuber- 
cle, but the nodules are seen to be made up of groups of fungi, surrounded 
by granulation tissue. This form of pulmonary actinomycosis is not in- 
frequent in oxen with advanced disease of the jaw or adjacent structures. 
(3) The cases in which there is more extensive destructive disease of the 
lungs, broncho-pneumonia, interstitial changes, and abscesses, the latter 



ACTINOMYCOSIS. 



237 



forming cavities large enough to be diagnosed during life. Actinomycotic 
lesions of other organs are often present in connection with the pulmonary 
disease; erosion of the vertebras, necrosis of the ribs and sternum, with 
node-like formations, subcutaneous abscesses, and occasionally metastases in 
all parts of the body. 

Symptoms. — The fever is of an irregular type and depends largely on 
the existence of suppuration. The cough is an important symptom, and 
the diagnosis in 18 of the cases was made during life by the discovery of 
the actinomyces. Death results usually with septic symptoms. Occasion- 
ally there is a condition simulating typhoid fever. The average duration 
of the disease was ten months. Recovery is very rare. Clinically the dis- 
ease closely resembles certain forms of pulmonary tuberculosis and of foetid 
bronchitis. It is not to be forgotten in the examination of the sputum 
that, as Bizzozero mentions, certain degenerated epithelial cells may be 
mistaken for the organism. The radiating leptothrix threads about the 
epithelium of the mouth sometimes present a striking resemblance. 

(c) Cutaneous Actinomycosis. — In several instances in connection with 
chronic ulcerative diseases of the skin the ray-fungus has been found. It 
is a very chronic affection resembling tuberculosis of the skin, associated 
with the development of tumors which suppurate and leave open sores, 
which may remain for years. 

(d) Cerebral Actinomycosis — Bollinger has reported an instance of 
primary disease of the brain. The symptoms were those of tumor. A 
second remarkable case has been reported by Gamgee and Delepine. The 
patient was admitted to St. George's Hospital with left-sided pleural effu- 
sion. At the post mortem three pints of purulent fluid were found in the 
left pleura; there was an actinomycotic abscess of the liver, and in the 
brain there were abscesses in the frontal, parietal, and temporo-sphenoidal 
lobes which contained the mycelium, but no clubs. A third case, reported 
by 0. B. Keller, had empyema necessitatis, which was opened and actino- 
mycetes were found in the pus. Subsequently she had Jacksonian epilepsy, 
for which she was trephined twice and abscesses opened, which contained 
actinomyces grain*. Death occurred after the second operation. 

Diagnosis. — The disease is in reality a chronic pyaemia. The only 
test is the presence of the actinomyces in the pus. Metastases may occur 
as in pyaemia and in tumors. The tendency, however, is rather to the pro- 
duction of a local purulent affection which erodes the bones and is very 
destructive. In cattle the disease may cause metastases without any suppura- 
tion; thus in a Montreal case the jaw and tongue were the seat of the most 
'•xtensive disease with very slight suppuration, while the lungs presented 
numbers of secondary growths containing the organisms. 

Treatment. — This is largely surgical and is practically that of py- 
aemia. Incision of the abscess, removal of the dead bone, and thorough 
irrigation are appropriate measures. Thomassen has recommended iodide 
of potassium, which, in doses of from 40 to 60 grains daily, has proved 
curative in a number of recent cases. 



238 



SPECIFIC INFECTIOUS DISEASES. 



XXXII. SYPHILIS. 

Definition. — A specific disease of slow evolution, propagated by in- 
oculation (acquired syphilis), or by hereditary transmission (congenital 
syphilis). In the acquired form the site of inoculation becomes the seat of 
a special tissue change — primary lesion. Within two or three months con- 
stitutional symptoms develop, with affections of the skin and mucous mem- 
branes — secondary lesions. After a period of months or years granulom- 
atous growths develop in the viscera, muscles, bones, or skin — tertiary 
lesions. And, finally, there are certain diseases, as tabes and general paresis, 
which are peculiarly prone to develop on the syphilitic soil — para- or meta- 
syphilitic affections. 

I. General Etiology and Morbid Anatomy. 

The nature of the virus is still doubtful. Lustgarten found in the 
hard chancre and in gummata a rod-shaped bacillus of 3 or 4 /a in length, 
which he claims is specific and peculiar to the disease. This organism 
closely resembles the smegma bacillus, which is found beneath the prepuce, 
but from its occurrence in gummatous growths it is hardly possible that 
they can be identical. Further observations are required before the ques- 
tion can be considered settled. 

Syphilis is peculiar to man, and cannot be transmitted to the lower 
animals. All are susceptible to the contagion, and it occurs at all ages. 

Modes of Infection. — (1) In a large majority of all cases the disease is 
transmitted by sexual congress, but the designation venereal disease (lues 
venerea) is not always correct, as there are many other modes of inoculation. 

(2) Accidental Infection. — In surgical and in midwifery practice phy- 
sicians are not infrequently inoculated. It is surprising that such acci- 
dents are not more common. General infection may occur without a local 
sore. Midwifery chancres are usually on the fingers, but I have met with 
one instance on the back of the hand. The lip chancre is the most common 
of these erratic or extra-genital forms, and may be acquired in many ways 
apart from direct infection. Mouth and tonsillar sores result as a rule 
from improper practices. Wet-nurses are sometimes infected on the nipple, 
and it occasionally happens that relatives of the child are accidentally con- 
taminated. One of the most lamentable forms of accidental infection is the 
transmission of the disease in humanized vaccine lymph. This, however, 
is extremely rare. The conditions under which it occurs have been already 
referred to (see Vaccination). 

(3) Hereditary Transmission. — This may be, and is, most common 
from (a) the father, the mother being healthy (sperm inheritance). It is, 
unfortunately, an every-day experience to see cases of congenital syphilis 
in which the infection is clearly paternal. A syphilitic father may, how- 
ever, beget a healthy child, even when the disease is fresh and full-blown. 
On the other hand, in very rare instances, a man may have had syphilis 
when young, undergo treatment, and for years present no signs of disease, 
and yet his first-born may show very characteristic lesions. Happily, in a 



SYPHILIS. 



239 



large majority of instances, when the treatment has been thorough, the 
offspring escape. The closer the begetting to the primary sore, the greater 
the chance of infection. A man with tertiary lesions may beget healthy 
children. As a general rule it may be said that with judicious treatment 
the transmissive power rarely exceeds three or four years. 

(b) Maternal transmission (germ inheritance). It is a remarkable and 
interesting fact that a woman who has borne a syphilitic child is herself 
immune, and cannot be infected, though she may present no signs of the 
disease. This is known as ColW law, and was thus stated by the distin- 
guished Dublin surgeon: " That a child born of a mother who is without 
obvious venereal symptoms, and which, without being exposed to any 
infection subsequent to its birth, shows this disease when a few weeks old, 
this child will infect the most healthy nurse, whether she suckle it, or 
merely handle and dress it; and yet this child is never known to infect its 
own mother, even though she suckle it while it has venereal ulcers of the 
lips and tongue." In a majority of these cases the mother has received a 
sort of protective inoculation, without having had actual manifestations of 
the disease. 

A woman with acquired syphilis is liable to bear infected children. 
The father may not be affected. In a large number of instances both 
parents are diseased, the one having infected the other, in which case the 
chances of fcetal infection are greatly increased. 

(c) Placental transmission. The mother may be infected after con- 
ception, in which case the child may be, but is not necessarily, born syph- 
ilitic. 

Morbid Anatomy. — The primary lesion, or chancre, shows: (a) A dif- 
fuse infiltration of the connective tissue with small, round cells, (b) 
Larger epithelioid cells, (c) Giant cells, (d) The Lustgarten bacilli, in 
small numbers.' . (e) Changes in the small arteries and veins, chiefly thick- 
ening of the intima, and. alterations in the nerve-fibres going to the part 
(Berkley). The sclerosis is due in part to this acute obliterative endart- 
eritis. Associated with the initial lesions are changes in the adjacent 
lymph-glands, which undergo hyperplasia, and finally become indurated. 

The secondary lesions .of syphilis are too varied for description here. 
They consist of condylomata, skin eruptions, affections of the eye, etc. 

The tertiary lesions consist of circumscribed tumors known as gum- 
mata, and of an arteritis, which, however, is not peculiar to the disease. 

Gummata. — Syphilomata develop in the bones or periosteum — here 
they are called nodes — in the muscles, skin, brain, lung, liver, kidneys, 
heart, testes, and adrenals. They vary in size from small, almost micro- 
scopic, bodies to large, solid tumors from 3 to 5 cm. in diameter. They 
are usually firm and hard, but in the skin and on the mucous membranes 
they tend to break down rapidly and ulcerate. On cross-section a medium- 
sized gumma has a grayish-white, homogeneous appearance, presenting 
in the centre a firm, caseous substance, and at the periphery a translucent, 
fibrous tissue. Often there are groups of three or more surrounded by 
dense sclerotic tissue. 

The arteritis will be considered in a separate section. 



240 



SPECIFIC INFECTIOUS DISEASES. 



II. Acquired Syphilis. 

Primary Stage. — This extends from the appearance of the initial sore 
until the onset of the constitutional symptoms, and has a variable dura- 
tion of from six to twelve weeks. The initial sore appears within a month 
after inoculation, and it first shows itself as a small red papule, which 
gradually enlarges and breaks in the centre, leaving a small ulcer. The 
tissue about this becomes indurated so that it ultimately has a gristly, car- 
tilaginous consistence — hence the name, hard or indurated chancre. The 
size attained is variable, and when small the sore may be overlooked, par- 
ticularly if it is just within the urethra. The glands in the lymph-district 
of the chancre enlarge and become hard. Suppuration both in the initial 
lesion and in the glands may occur as a secondary change. The general 
condition of the patient in this stage is good. There may be no fever and 
no impairment of health. 

Secondary Stage. — The first constitutional symptoms are usually mani- 
fested within three months of the appearance of the primary sore. They 
rarely develop earlier than the sixth or later than the twelfth week. The 
symptoms are: (a) Fever, slight or intense, and very variable in charac- 
ter. A mild continuous pyrexia is not uncommon, the temperature not 
rising above 101°. The fever may have a distinctly remittent character; 
but the most remarkable and puzzling type, which is very apt to lead to 
error in diagnosis, is the intermittent syphilitic fever. It may come on 
within a month after exposure and rise to 104° or 105°, with oscilla- 
tions of 5° or 6° (Yeo); A remarkable case is reported by Sidne} 
Phillips, in which pyrexia persisted for months, with paroxysms resem- 
bling in all respects tertian ague, and which resisted quinine and yielded 
promptly to mercury and potassium iodide. Although usually a secondary 
manifestation, the fever of syphilis may occur late in the disease. Prac- 
titioners are scarcely alive to the frequency and importance of syphilitic 
fever. Janeway has called attention to cases in which the diagnosis of 
pulmonary tuberculosis had been made. 

(b) Anwmia. — In many cases the syphilitic poison causes a pronounced 
anaemia which gives to the face a muddy pallor, and there may even be a 
light-yellow tingeing of the conjunctivae or of the skin, a haematogenous 
icterus. This syphilitic cachexia may in some instances be extreme. The 
red blood-corpuscles do not show any special alterations. The blood-count 
may fall to three millions per cubic millimetre, or even lower. The anaemia 
may develop suddenly. In a case of syphilitic arthritis in a young girl 
following three or four inunctions of mercury the blood-count fell below 
two millions per cubic millimetre in a few days. 

(c) Cutaneous Lesions. — The earliest and most common is a macular 
syphilide or syphilitic roseola, which occurs on the trunk, and on the front of 
the arms. The face is often exempt. The spots, which are reddish -brown 
and symmetrically arranged, persist for a week or two. There may be mul- 
tiple relapses of roseola, sometimes at long intervals, even eleven years (Four- 
nier). The papular syphilide, which forms acne-like indurations about the 
face and trunk, is often arranged in groups. Other forms are the pustular 



SYPHILIS. 241 

rash, which may so closely simulate variola that the patient may be sent to 
a small-pox hospital. A squamous syphilide occurs, not unlike ordinary 
psoriasis, except that the scales are less abundant. The rash is more copper- 
colored and not specially confined to the extensor surfaces. 

In the moist regions of the skin, such as the perineum and groins, the 
axillae, between the toes, and at the angles of the mouth, the so-called 
mucous patches develop, which are flat, warty outgrowths, with well-defined 
margins and surfaces covered with a grayish secretion. They are among 
the most distinctive lesions of syphilis. 

Frequently the hair falls out (alopecia), either in patches or by a gen- 
eral thinning. Occasionally the nails become affected (syphilitic onychia). 

(d) Mucous Lesions. — With the fever and the roseolous rash the throat 
and mouth become sore. The pharyngeal mucosa is hyperaemic, the ton- 
sils are swollen and often present small, kidney-shaped ulcers with grayish- 
white borders. Mucous patches are seen on the inner surfaces of the cheeks 
and on the tongue and lips. Sometimes on the tongue there are whitish 
spots (leucomata), which are seen most frequently in smokers, and which 
Hutchinson regards as the joint result of syphilitic glossitis and the irri- 
tation of hot tobacco-smoke. Hypertrophy of the papillae in various por- 
tions of the mucous membrane produces the syphilitic warts or condylo- 
mata which are most frequent about the vulva and anus. 

(e) Other Lesions. — Iritis is common, and usually affects one eye be- 
fore the other. It develops in from three to six months after the chancre. 
There may be only slight ciliary congestion in mild cases, but in severer 
forms there is great pain, and the condition is serious and demands care- 
ful management. Choroiditis and retinitis are rare secondary symptoms. 
Ear affections are not common in the secondary stage, but instances are 
found in which sudden deafness develops, which may be due to labyrinth- 
ine disease; more commonly the impaired hearing is due to the extension 
of inflammation from the throat to the middle ear. Epididymitis and 
parotitis are rare. Jaundice may occur, the icterus syphiliticus precox. 

Tertiary Stage. — No hard and fast line can be drawn between the 
lesions of the secondary and those of the tertiary period; and, indeed, in 
exceptional cases, manifestations which usually appear late may set in even 
before the primary sore has properly healed. The special affections of this 
stage arc certain skin eruptions, gummatous growths in the viscera, and 
amyloid degenerations. 

(a) The late syphilides show a greater tendency to ulceration and de- 
struction of the deeper layers of the skin, so that in healing scars are left. 
They are also more scattered and seldom symmetrical. One of the most 
characteristic of the tertiary syphilides is rupia, the dry stratified crusts 
of which cover an nicer which involves the deeper layers of the skin and 
in healing leaves a scar. 

(b) Gummata. — These may develop in the skin, subcutaneous tissue, 
muscles, or internal organs. The general character has been already de- 
scribed. When they develop in the skin they tend to break down and 
ulcerate, leaving ugly sores which heal with difficulty. Tn the solid organs 
they undergo fibroid transformation and produce puckering and deformity. 



242 



SPECIFIC INFECTIOUS DISEASES. 



On the mucous membranes these tertiary lesions lead to ulceration, in the 
healing of which cicatrices are formed; thus, in the larynx great narrow- 
ing may result, and in the rectum ulceration with fibroid thickening and 
retraction may lead to stricture. Gummatous ulcers may be infective. 

(c) Amyloid Degeneration. — Syphilis plays a most important role in 
the production of this affection. Of 244 instances analyzed by Fagge, 76 
had syphilis, and of these 42 had no bone lesions. It follows the acquired 
form and is very common in association with rectal syphilis in women. In 
congenital lues amyloid degeneration is rare. 

(d) Para- or Metasyphilitic Affections. — Certain disorders not actually 
syphilitic, yet so closely connected that a large proportion of the cases have 
had the disease, are termed by Fournier parasyphilitic (Les Affections 
Parasyphilitiques, 1894). These affections are not exclusively and neces- 
sarily caused by syphilis, and they are not influenced by specific treatment. 
The chief of them are locomotor ataxia, dementia paralytica, certain types 
of epilepsy, and, we may add, arterio-sclerosis. 

III. Coxgexital Syphilis. 

"With the exception of the primary sore, every feature of the acquired 
disease may be seen in the congenital form. 

The intra-uterine conditions leading to the death of the foetus do not 
here concern us. The child may be born healthy-looking, or with well- 
marked evidences of the disease. In the majority of instances the former 
is the case, and within the first month or two the signs of the disease 
appear. 

Symptoms. — (a) At Birth. — When the disease exists at birth the child 
is feebly developed and wasted, and a skin eruption is usually present, 
commonly in the form of bullae about the wrists and ankles, and on the 
hands and feet (pemphigus neonatorum). The child snuffles, the lips are 
ulcerated, the angles of the mouth fissured, and there is enlargement of 
the liver and spleen. The bone symptoms may be marked, and the epiphy- 
ses may even be separated. In such cases the children rarely survive 
long. 

(b) Early Manifestations. — When born healthy the child thrives, is fat 
and plump, and shows no abnormity whatever; then from the fourth to 
the eighth week, rarely later, a nasal catarrh develops, syphilitic rhinitis, 
which impedes respiration, and produces the characteristic symptom which 
has given the name snuffles to the disease. The discharge may be sero- 
purulent or bloody. The child nurses with great difficulty. In severe cases 
ulceration takes place with necrosis of the bone, leading to a depression 
at the root of the nose and a deformity characteristic of congenital syphilis. 
This coryza may be mistaken at first for an ordinary catarrh, but the co- 
existence of other manifestations usually makes the diagnosis clear. The 
disease may extend into the Eustachian tubes and middle ears and lead 
to deafness. 

The cutaneous lesions develop with or shortly after the onset of the 
snuffles. The skin often has a sallow, earthy hue. The eruptions are first 



SYPHILIS. 



243 



noticed about the nates. There may be an erythema or an eczematons 
condition, but more commonly there are irregular reddish-brown patches 
with well-defined edges. A papular syphilide in this region is by no means 
uncommon. Fissures develop about the lips, either at the angles of the 
mouth or in the median line. These rhagades, as they are called, are very 
characteristic. There may be marked ulceration of the muco-cutaneous 
surfaces. The secretions from these mouth lesions are very virulent, and 
it is from this source that the wet-nurse is usually infected. Not only the 
nurse, but members of the family, may be contaminated. There are in- 
stances in which other children have been accidentally inoculated from 
a syphilitic infant. The hair of the head or of the eyebrows may fall out. 
The syphilitic onychia is not uncommon. Enlargement of the glands is 
not so frequent in the congenital as in the acquired disease. When the 
cutaneous lesions are marked, the contiguous glands can usually be felt. 
As pointed out by Gee, the spleen is enlarged in many cases. The condi- 
tion may persist for a long time. Enlargement of the liver, though often 
present, is less significant, since in infants it may be due to various causes. 
These are among the most constant symptoms of congenital syphilis, and 
usually develop between the third and twelfth weeks. Frequently they 
are preceded by a period of restlessness and wakefulness, particularly at 
night. Some authors have described a peculiar syphilitic cry, high-pitched 
and harsh. Among rarer manifestations are haemorrhages — the syphilis 
hemorrhagica neonatorum. The bleeding may be subcutaneous, from the 
* mucous surfaces, or, when early, from the umbilicus. All of such cases, 
however, are not syphilitic, and the disease must not be confounded with 
the acute hsemoglobinuria of new-born infants, which Winckel describes 
as occurring in epidemic form, and which is probably an acute infectious 
disorder. 

(c) Late Manifestations. — Children with congenital syphilis rarely 
thrive. Usually they present a wizened, wasted appearance, and a pre- 
maturely aged face. In the cases which recover, the general nutrition 
may remain good and the child may show no further manifestations of 
the disease; commonly, however, at the period of second dentition or at 
puberty the disease reappears. Although the child may have recovered 
from the early lesions, it does not develop like other children. Growth is 
slow, development tardy, and there are facial and cranial characteristics 
which often render the disease recognizable at a glance. A young man of 
nineteen or twenty may neither look older nor be more developed than a 
boy of ten or twelve. Fournier describes this condition as infantilism. 
The forehead is prominent, the frontal eminences are marked, and the 
skull may be very asymmetrical. The bridge of the nose is depressed, the 
tip retrousse. The lips are often prominent, and there are striated lines 
running from the corners of the mouth. The teeth are deformed and may 
present appearances which Jonathan Hutchinson claims arc specific and 
peculiar. The upper central incisors of the permanent set are the teetli 
which give information. The specific alterations are — the teeth are peg- 
shaped, stunted in length and breadth, and narrower at the cutting edge 
than at the root. On the anterior surface the enamel is well formed, and 



244 



SPECIFIC INFECTIOUS DISEASES. 



not eroded or honeycombed. At the cutting edge there is a single notch, 
usually shallow, sometimes deep, in which the dentine is exposed. 

Among late manifestations, particularly apt to appear about puberty, 
is the interstitial keratitis, which usually begins as a slight steaminess of 
the cornese, which present a ground-glass appearance. It affects both eyes, 
though one is attacked before the other. It may persist for months, and 
usually clears completely, though it may leave opacities, which prevent 
clear vision. Iritis may also occur. Of ear affections, apart from those 
which develop as a sequence of the pharyngeal disease, a form occurs about 
the time of puberty or earlier, in which deafness comes on rapidly and per- 
sists in spite of all treatment. It is unassociated with obvious lesions, 
and is probably labyrinthine in character. Bone lesions, occurring oftenest 
after the sixth year, are not rare among the late manifestations of hereditary 
syphilis. The tibise are most frequently attacked. It is really a chronic 
gummatous periostitis, which gradually leads to great thickening of the 
bone. The nodes of congenital syphilis, which are often mistaken for 
rickets, are more commonly diffuse and affect the bones of the upper and 
lower extremities. They are generally symmetrical and rarely painful. 
They may develop late, even after the twenty-first year. 

Joint lesions are rare. Clutton has described a symmetrical synovitis 
of the knee in hereditary syphilis. Enlargement of the spleen, sometimes 
with the lymph-glands, may be one of the late manifestations, and may 
occur either alone or in connection with disease of the liver. 

Gummata of the liver, brain, and kidneys have been found in late 
hereditary syphilis. 

Is syphilis transmitted to the third generation? The general opinion 
is that the recorded cases scarcely stand criticism. Occasionally, however, 
cases of pronounced congenital syphilis are met with in the children of 
parents who are perfectly healthy, and who have not, so far as is known, 
had syphilis, and yet, as remarked by Coutts, who reported such a group 
of cases, they do not bear careful scrutiny. This is the opinion of the lead- 
ing syphilographers. Personally, I have never met with even a suspicious 
instance. On the other hand, I know now a number of perfectly healthy 
children, one of whose grandfathers was syphilitic. 

IV. Visceral Syphilis. 

a. Syphilis of the Brain and Cord. — The following lesions occur: 
(1) Gummata, forming definite tumors, ranging in size from a pea to 
a walnut. They are usually multiple and attached to the pia mater, some- 
times to the dura. Very rarely they are found unassociated with the me- 
ninges. When small they present a uniform, translucent appearance, but 
when large the centre undergoes a fibro-caseous change, while at the 
periphery there is a firm, translucent, grayish tissue. They may closely 
resemble large tuberculous tumors. The growths are most common in the 
cerebrum. They may be multiple and may even attain a considerable size 
without becoming caseous. Occasionally gummata undergo cystic degen- 
eration. In the cord large gummatous growths are not so common. In 



SYPHILIS. 



245 



an instance recently reported by me a tumor, from three eighths to one 
fourth of an inch in diameter, was completely within the cord opposite 
the fourth cervical nerve, and there were numerous gummata in the cauda 
equina. 

(2) Gummatous Meningitis. — This constantly occurs in the neighbor- 
hood of the larger growths, and there may be local meningeal thickening 
several centimetres in extent, in which the pia is infiltrated and the arteries 
greatly thickened. This by no means uncommon form may run a subacute 
or a chronic course. 

(3) Gummatous Arteritis. — The lesions may be confined to the arteries 
which present the nodular tumors to be described hereafter. 

(4) Foci of sclerosis, which Lancereaux holds may be distinguished from 
non-specific forms by a much greater tendency of the neuroglia elements 
to undergo fatty transformation, and by the secondary alterations, as areas 
of softening, which occur in the neighborhood. Neither the diffuse nor 
the nodular cerebral sclerosis, met with particularly in children, appears 
to have any special relation to inherited syphilis. 

(5) Whether a localized encephalitis or myelitis can result from the 
action of the syphilitic poison without involvement of the blood-vessels is 
doubtful. In a case of multiple arterial gummata recently in my ward, 
Thomas found in the lumbar region of the cord foci of inflammatory soft- 
ening. 

Secondary Changes. — In the brain gummatous arteritis is one of the 
common causes of softening, which may be extensive, as when the middle 
cerebral artery is involved, or when there is a large patch of syphilitic 
meningitis. In such instances the process is really a meningoencepha- 
litis, and the symptoms are due to the secondary changes in the brain-sub- 
stance, not directly to the gumma. In the neighborhood of a gummatous 
growth intense encephalitis or myelitis may develop, and within a few days 
change the clinical picture. Gummatous arteritis may lead to weakening 
of the Avail of the vessel and rupture with meningeal haemorrhage. 

Syphilitic disease of the nerve-centres may occur in the inherited or 
acquired form, more commonly in the latter. In the congenital cases the 
tumors usually develop early, but may be as late as the twenty-first year 
(H. C. Wood). In the acquired form the nerve lesions belong, as a rule, 
to the late manifestations, and patients may have quite forgotten the ex- 
istence of a primary infection, and in very many instances the secondary 
manifestations have been slight. Heubner, to whom we owe so much in 
connection with this subject, has seen them as late as the thirtieth year. 
On the other hand, in exceptional instances, they may occur very early, and 
severe convulsions with hemiplegia have been reported within three months 
of the primary sore. The discussion at the Eoyal Medical and Chirurgica! 
Society (T>. M. J., 1895, vol. i), and Lydston's paper (Jour. Am. Mod. 
Assoc., 1895, vol. i), show that various affections of the nervous system 
are by no means uncommon during the secondary stage of the disease. 

Symptoms. — The chief features of cerebral syphilis are those of tumor, 
which will be considered subsequently under that section. They may be 
classified here as follows: 



246 



SPECIFIC INFECTIOUS DISEASES. 



(1) Psychical features. A sudden and violent onset of delirium may 
be the first symptom. In other instances prior to the occurrence of de- 
lirium there have been headache, alteration of character, and loss of mem- 
ory. The condition may be accompanied by convulsions. There may be no 
neuritis, no palsy, and no localizing symptoms. 

(2) More commonly following headache, giddiness, or an excited state 
which may amount to delirium, the patient has an epileptic seizure or 
develops hemiplegia, or there is involvement of the nerves of the 
base. Some of these cases display a prolonged torpor, a special feature of 
brain syphilis to which both Buzzard and Heubner have referred, which 
may persist for as long as a month. H. C. Wood describes with this 
a state of automatism occurring particularly at night, in which the 
patient behaves like a "restless nocturnal automaton rather than a 
man." 

(3) A clinical picture of general paralysis — dementia paralytica. The 
question is still in dispute whether this syphilitic encephalopathy, which 
so closely resembles general paralysis, is a distinct and independent affec- 
tion. Miclde, who has carefully reviewed the subject, concludes that 
syphilis may directly produce the inflammatory changes in the brain, while 
in other instances it directly predisposes to this affection. It is a some- 
what remarkable feature that the cases which present the clinical picture 
of general paresis are most frequently those which have not had any local- 
izing symptoms, and they may not have convulsions until the disease is 
well advanced. 

(4) Many cases of cerebral syphilis display the symptoms of brain 
tumor — headache, optic neuritis, vomiting, and convulsions. Of these 
symptoms convulsions are the most important, and both Fournier and 
Wood have laid great stress on the value 'of this symptom in persons over 
thirty. The first symptoms may, however, rather resemble those of em- 
bolism or thrombosis; thus there may be sudden hemiplegia, with or with- 
out loss of consciousness. 

The symptoms of spinal syphilis are extremely varied and may be 
caused by large gummatous growths attached to the meninges, in which 
case the features are those of tumor; by gummatous arteritis with second- 
ary softening; by meningitis with secondary cord changes; or by scleroses 
developing late in the disease, the relation of which to syphilis is still ob- 
scure. Erb's syphilitic myelitis will be considered under the spastic para- 
plegias. 

Diagnosis. — The history is of the first importance, but it may be ex- 
tremely difficult to get a reliable account. Careful examination should be 
made for traces. of the primary sore, for the cicatrices of bubo, for scars of 
the skin eruption or throat ulcers, and for bone lesions. The character 
of the symptoms is often of great assistance. They are multiform, vari- 
able, and often such as could not be explained by a single lesion; thus 
there may be anomalous spinal symptoms or involvement of the nerves of" 
the brain on both sides. And lastly the result of treatment has a definite 
bearing on the diagnosis, as the symptoms may clear up and disappear with 
the use of antisyphilitic remedies. 



SYPHILIS. 



247 



b. Syphilis of the Lung. 

This is a very rare disease. During twenty-five years I have not seen 
more than half a dozen specimens in which there was no question as to the 
nature of the trouble. Fowler states that he has recently visited the muse- 
ums of the London hospitals and at the Koyal College of Surgeons, and can 
find only twelve specimens illustrating syphilitic lesions of the lungs, two 
of which are doubtful. For the most full and satisfactory consideration 
of pulmonary syphilis, the reader is referred to chapter xxxvii of Fowler 
and Godlee's work on Diseases of the Lungs. 

Etiology and Morbid Anatomy. — Syphilis of the lung occurs under the 
following forms: 

(1) The white pneumonia of the foetus. This may affect large areas or 
an entire lung, which then is firm, heavy, and airless, even though the 
child may have been born alive. On section it has a grayish-white appear- 
ance — the so-called white hepatization of Virchow. The chief change is 
in the alveolar walls, which are greatly thickened and infiltrated, so that, 
as Wagner expressed it, the condition resembles a diffuse syphiloma. In 
the early stages, for example, in a seven or eight months' foetus, there may 
be scattered miliary foci of this induration chiefly about the arteries. The 
air-cells are filled with desquamated and swollen epithelium. 

(2) In the form of definite gummata, which vary in size from a pea to 
a goose-egg. They occur irregularly scattered through the lung, but, as 
a rule, are more numerous toward the root. They present a grayish-yellow 
caseous appearance, are dry and usually imbedded in a translucent, more 
or less firm, connective tissue. In a case from my wards described by 
Councilman, there was extensive involvement of the root of the lungs. 
Bands of connective tissue passed inward from the thickened pleura and 
between these strands and surrounding the gummata there was in places 
a mottled red pneumonic consolidation. In the caseous nodules there is 
typical hyaline degeneration. Councilman describes as the primary lesion, 
atrophy of the alveolar walls with hyaline degeneration of the capillaries; 
not the syphilitic endarteritis, which is well marked, and to which the 
lesions are attributed. The bronchi are usually involved, and surrounding 
the gummata there may be a diffuse broncho-pneumonia, which does not 
appear to have any peculiar characters. 

(3) A majority of authors follow Yirchow in recognizing the fibrous 
interstitial pneumonia at the root of the lung and passing along the bron- 
chi and vessels as probably syphilitic. This much may be said, that in cer- 
tain cases gummata are associated with these fibroid changes. Again, this 
condition alone is found in persons with well-marked syphilitic history or 
with other visceral lesions. It seems in many instances to be a purely 
sclerotic process, advancing sometimes from the pleura, more commonly 
from the root of the lung, and invading the interlobular (issue, gradually 
producing a more or less extensive fibroid change. It rarely involves more 
than a portion of a lobe or portions of the lobes at the root of the lung. 
The bronchi are often dilated. 

Symptoms. — Is there a syphilitic phthisis, an ulcerative and destructive 
disease, due to lues? Personally I have no knowledge of such an affec- 



2 ±8 



SPECIFIC INFECTIOUS DISEASES. 



tion, either clinically or anatomically, and the cases which I have seen 
demonstrated do not seem to me to have characters distinctive enough to 
separate them from ordinary tuberculous phthisis. Certain French writers 
recognize not only a chronic syphilitic phthisis but an acute syphilitic 
pneumonia in adults, simulating acute pneumonic phthisis. Clinically, 
pulmonary syphilis is not of much importance, as the cases can rarely be 
diagnosed, and the symptoms which arise are usually those of bronchi- 
ectasis or of chronic interstitial pneumonia. The white pneumonia is usu- 
ally found in the still-born. 

Diagnosis. — It is to be borne in mind, in the first place, that hospital 
physicians and pathologists the world over bear witness to the extreme 
rarity of lung syphilis. In the second place, the therapeutic test upon 
which so much reliance is placed is by no means conclusive. With pul- 
monary tuberculosis there should now be no confusion, owing to the readi- 
ness with which the presence of bacilli is determined. Bronchiectasy in 
the lower lobe of a lung, dependent upon an interstitial pneumonia of 
syphilitic origin, could not be distinguished from any other form of the 
disease. In persons with well-marked syphilitic lesions elsewhere, when 
obscure pulmonary symptoms occur, or if there are signs of chronic inter- 
stitial pneumonia with dilated bronchi, and no tubercle bacilli are present, 
the condition may possibly be due to syphilis. So far as my experience 
goes, tuberculous phthisis occurring in a syphilitic subject has no special 
peculiarities. The lesions of syphilis and tuberculosis could of course co- 
exist in a lung. 

c. Syphilis of the Liver. 

This occurs in three forms: (a) Diffuse Syphilitic Hepatitis. — This is 
most common in cases of congenital syphilis. The liver preserves its form, 
is large, hard, and resistant. Sometimes it has a yellow look, compared 
by Trousseau to sole-leather, or an appearance not unlike the amyloid 
liver. Careful inspection shows grayish or whitish points and lines cor- 
responding to the interlobular new growth. Microscopically, great increase 
in the connective tissue is seen, and in many places foci of small-celled 
infiltration. Sometimes these nodules are visible, forming firm miliary 
gummata which in cicatrizing produce more or less deformity. Larger 
gummata may also be present. 

(b) Gummata. — As a result of congenital syphilis these may occur in 
childhood or in adult life. In acquired syphilis they rarely come on before 
the second year after infection. In the early stage there are pale grayish 
nodules, varying in size from a pea to a marble. The larger present yellow- 
ish centres at first; but later there is a " pale yellowish, cheese-like nodule 
of irregular outline, surrounded by a fibrous zone, the outer edge of which 
loses itself in the lobular tissue, the lobules dwindling gradually in its grasp. 
This fibrous zone is never very broad; the cheesy centre varies in consist- 
ence from a gristle-like toughness to a pulpy softness; it is sometimes 
mortar-like, from cretaceous change " (Wilks). When numerous, the most 
extensive deformity of the liver is produced in the gradual healing of these 
gummata. On the surface there are deep, scar-like depressions, and the en- 
tire organ may be divided into a cluster of irregular masses, held together by 



SYPHILIS. 



249 



fibrous tissue. To this condition the term botyroid has been given, from 
its resemblance to a bunch of grapes. As a rule, the gummata gradually 
undergo fibroid transformation. They may, however, soften and liquefy, 
and, according to Wilks, may form a fluctuating tumor. 

(c) Occasionally the syphilitic changes are chiefly manifested in Glis- 
son's sheath, in a thickening of the capsule, producing perihepatitis, and 
increase in the connective tissue in the portal canals, so that on section 
the organ presents a number of branching fibrous scars which may cause 
considerable deformity. 

Symptoms. — The symptoms of syphilitic hepatitis are very variable. 
In the new-born icterus is not uncommon, but the condition of the liver 
can scarcely be recognized. In the adult there are three groups of cases: 

The patient presents a picture of cirrhosis of the liver; there are di- 
gestive disturbances, slight icterus, loss of weight, and ascites. If signs 
of syphilis are present in other organs, the condition may be suspected, 
or if after removal of the fluid the liver is felt to be extremely irregular, 
the diagnosis may be made almost with certainty. These cases are com- 
mon, and with proper treatment get well; they form an important con- 
tingent of the reputed recoveries in ordinary cirrhosis of the liver. 

In a second group of cases the patient is ansemic, passes large quan- 
tities of pale urine containing albumin and tube-casts; the liver is en- 
larged, perhaps irregular, and the spleen also is enlarged. Dropsical symp- 
toms may supervene, or the patient may be carried off by some intercurrent 
disease. Extensive amyloid degeneration of the spleen, the intestinal mu- 
cosa, and of the liver, with gummata, are found. 

Thirdly, the gummata may form an irregular tumor on the right or 
left lobe, perhaps with very few or very obscure symptoms. The diagnosis 
may be doubtful until some other evidence of syphilis develops. I have 
recorded several illustrative cases in my Lectures on Abdominal Tumors. 

The diagnosis of syphilis of the liver is very important, since upon it 
the proper treatment depends. If with a history of infection the liver 
is enlarged and irregular, and the general health fairly good, the condi- 
tion is probably syphiloma. 

d. Syphilis of the Digestive Tract. 

The cesophagus is very rarely affected. Stenosis is the usual result. 
Syphilis of the stomach is excessively rare. Flexner has reported a remark- 
able case in association with gummata of. the liver. He has collected 14 
cases in the literature. Syphilitic ulceration has been found in the small 
intestine and in the caecum. 

The most common seat of syphilitic disease in this tract is the rectum. 
The affection is found most commonly in women, and results from the 
development of gummata in the submucosa above the internal sphincter. 
The process is slow and tedious, and may last for years before it finally 
induces stricture. The symptoms are usually those of narrowing of the 
lower bowel. The condition is readily recognized by rectal examination. 
The history of gradual on-coming stricture, the state of the patient, and 
the fact that there is a hard, fibrous narrowing, not an elevated crater-like 
ulcer, usually render easy the diagnosis from malignant disease. In medi- 



250 



SPECIFIC INFECTIOUS DISEASES. 



cal practice these cases come under observation for other symptoms, par- 
ticularly amyloid degeneration; and the rectal disease may be entirely over- 
looked, and only discovered post mortem. 
e. Circulatory System. 

Syphilis of the Heart. — A fresh, warty endocarditis due to syphilis is 
not recognized, though occasionally in persons dead of the disease this 
form is present, as is not uncommon in conditions of debility. Outgrowths 
on the valves in connection with gummata have been reported by Janeway 
and others. In a recent study of the subject Loomis groups the lesions 
into: (1) Gummata, recent or old; (2) fibroid induration, localized or dif- 
fuse; (3) amyloid degeneration; and (4) endarteritis obliterans. I. Adler 
claims that changes in the blood-vessels of the walls of the heart are com- 
mon both in congenital and acquired syphilis, even in cases without clin- 
ical symptoms or gross lesions. 

Eupture may take place, as in the cases reported by Dandridge and 
Xalty, or sudden death, as in the cases of Cayley and Pearce Gould; in- 
deed, sudden death is frequent, occurring in 21 of 63 cases (Mracek). 

Syphilis of the Arteries. — Syphilis is believed to play an important role 
in arterio-sclerosis and aneurism. Its connection with these processes will 
be considered later; here we shall refer only to the syphilitic arteritis, which 
occurs in two forms: 

(a) An obliterating endarteritis, characterized by a proliferation of the 
subendothelial tissue. The new growth lies within the elastic lamina, and 
may gradually fill the entire lumen; hence the term obliterating. The > 
media and adventitia are also infiltrated with small cells. This form of 
endarteritis described by Heubner is not, however, characteristic of syphi- 
lis, and its presence alone in an artery could not be considered pathog- 
nomonic. If, however, there are gummata in other parts, or if the con- 
dition about to be described exists in adjacent arteries, the process may 
be regarded as syphilitic. 

(b) Gummatous Periarteritis. — With or without involvement of the 
intima., nodular gummata may develop in the adventitia of the artery, pro- 
ducing globular or ovoid swellings, which may attain considerable size. 
They are not infrequently seen in the cerebral arteries, which seem to be 
specially prone to this affection. This form is specific and distinctive of 
syphilis. The disease usually affects the smaller vessels and may be found 
in the coronary arteries, and particularly in those of the brain. 

F, Renal Syphilis. — (a) Gummata occasionally develop in the kidneys, 
particularly in cases in which there is extensive gummatous hepatitis. 
They are rarely numerous, and occasionally lead to scattered cicatrices. 
Clinically the affection is not recognizable. 

(b) Acute Syphilitic Nephritis. — This condition has been carefully 
studied by the French writers and by Lafleur, of Montreal. It is estimated 
to occur in the secondary stage in about 3.8 per cent, and may develop in 
from three to six months, sometimes later, from the initial lesion. The 
outlook is good, though often the albuminuria may persist for months; 
more rarely chronic Bright's disease develops. In a few instances syph- 
ilitic nephritis has proved rapidly fatal in a fortnight or three weeks. The 



SYPHILIS. 



251 



lesions are not specific, but are similar to those in other acute infec- 
tions. 

g. Syphilitic Orchitis. — This affection is of special significance to the 
physician, as its detection frequently clinches the diagnosis in obscure 
internal disorders. Syphilis occurs in the testes in two forms: 

(a) The gummatous growth, forming an indurated mass or group of 
masses in the substance of the organ, and sometimes difficult to distin- 
guish from tuberculous disease. The area of induration is harder and it 
affects the body of the testes, while tubercle more commonly involves the 
epididymis. It rarely tends to invade the skin, or to break down, soften, 
and suppurate, and is usually painless. 

(6) There is an interstitial orchitis regarded as syphilitic, which leads 
to fibroid induration of the gland and gradually to atrophy. It is a slow, 
progressive change, coming on without pain, usually involving one organ 
more than another. 

General Diagnosis of Syphilis. — There is seldom any doubt 
concerning the existence of syphilitic lesions. The negative statements 
of the patient must be taken with extreme caution, as persons will lie 
deliberately with reference to primary infection, when it is in their best 
interest to make a straightforward truthful statement. It is to be remem- 
bered that syphilis is common in the community, and there are probably 
more families with a luetic than with a tuberculous taint. It is possible 
that the primary sore may have been of trifling extent, or urethral and 
masked by a gonorrhoea, and the patient may not have had severe secondary 
symptoms, but such instances are extremely rare. Inquiries should be 
made into the history to ascertain if the patient has had skin rashes, sore 
throat, or if the hair has fallen out. Careful inspection should be made 
of the throat and skin for signs of old lesions. Scars in the groins, the 
result of buboes, are uncertain evidences of syphilitic infection. The 
cicatrices on the legs are often copper-colored, though this can not be 
regarded as peculiar to syphilis. The bones should be examined for nodes. 
In doubtful cases the scar of the primary sore may be found, or there may 
be signs of atrophy or of hardening of the testes. In women, special stress 
has been laid upon the occurrence of frequent miscarriages, which, in con- 
nection with other circumstances, are always suggestive. 

In the congenital disease, the occurrence within the first three months 
of snuffles and skin rash is conclusive. Later, the characters of the syphi- 
litic fades, already referred to, often give a clew to the nature of some 
obscure visceral lesion. Other distinctive features are the symmetrical de- 
velopment of nodes on the bones, and the interstitial keratitis. 

In doubtful cases much stress is laid by some writers upon the thera- 
peutic test, by placing the patient upon antisyphilitic treatment. In the 
case of an obstinate skin rash of doubtful character, which has resisted all 
other forms of medication, this has much greater weight than in obscure 
visceral lesions. I have on several occasions known such marked improve- 
ment to follow large doses of iodide of potassium that the diagnosis of 
syphilitic lesion was greatly strengthened, but the subsequent course and 
the post mortem have shown that the disease was not syphilis. 
16 



252 



SPECIFIC INFECTIOUS DISEASES. 



Prophylaxis. — Irregular intercourse has existed from the beginning 
of recorded history, and unless man's nature wholly changes — and of this 
we can have no hope — will continue. Kesisting all attempts at solution, 
the social evil remains the great blot upon our civilization, and inextricably 
blended with it is the question of the prevention of syphilis. Two meas- 
ures are available — the one personal, the other administrative. 

Personal purity is the prophylaxis which we, as physicians, are espe- 
cially bound to advocate. Continence may be a hard condition (to some 
harder than to others), but it can be borne, and it is our duty to urge this 
lesson upon young and old who seek our advice in matters sexual. Cer- 
tainly it is better, as St. Paul says, to marry than to burn, but if the former 
is not feasible there are other altars than those of Venus upon which a 
young man may light fires. He may practise at least two of the five means 
by which, as the physician Eondibilis counselled Panurge, carnal concupis- 
cence may be cooled and quelled — hard work of body and hard work of 
mind. Idleness is the mother of lechery; and a young man will find that 
absorption in any pursuit will do much to cool passions which, though 
natural and proper, cannot in the exigencies of our civilization always ob- 
tain natural and proper gratification. 

The second measure is a rigid and systematic regulation of prostitu- 
tion. The state accepts the responsibility of guarding citizens against 
small-pox or cholera, but in dealing with syphilis the problem has been 
too complex and has hitherto bafiied solution. On the one hand, inspec- 
tion, segregation, and regulation are difficult, if not impossible, to carry 
out; on the other hand, public sentiment, in Anglo-Saxon communities 
at least, is as yet bitterly opposed to this plan. While this feeling, though 
unreasonable, as I think, is entitled to consideration, the choice lies be- 
tween two evils — licensing, even imperfectly carried out, or widespread 
disease and misery. If the offender bore the cross alone, I would say, 
forbear; but the physician behind the scenes knows that in countless in- 
stances syphilis has wrought havoc among innocent mothers and helpless 
infants, often entailing life-long suffering. It is for them he advocates 
protective measures. 

Treatment. — We must admit that various constitutions react very 
differently to the poison of syphilis. There are individuals who, although 
receiving brief and unsatisfactory treatment, display for years no traces of 
the disease. On the other hand, there are persons thoroughly and sys- 
tematically treated from the outset who from time to time show well- 
marked indications of syphilis. Certainly there are grounds for the 
opinion that persons who have suffered very slightly from secondary symp- 
toms are more prone to have the severer visceral lesions of the later stage. 

When we consider that syphilis is one of the most amenable of all dis- 
eases to treatment, it is lamentable that the later stages which come under 
the charge of the physician are so common. This results, in great part, 
from carelessness of the patient, who, wearied with treatment, cannot un- 
derstand why he should continue to take medicine after all the symptoms 
have disappeared; but, in part, the profession also is to blame for not 
insisting more urgently in every instance that acquired syphilis is not cured 



SYPHILIS. 



253 



in a few months, but takes at least two years, during which time the pa- 
tient should be under careful supervision. The treatment of the disease 
is now practically narrowed to the use of two remedies, Justly termed spe- 
cifics — namely, mercury and iodide of potassium. The former is of special 
service in the secondary, the latter in the tertiary manifestations of the 
disease; but they are often combined with advantage. 

Mercury may be given by the mouth in the form of gray powder, the 
hydrargyrum cum creta, which Hutchinson recommends to be given in 
pills, one-grain doses with a grain of Dover's powder. One pill from four 
to six times a day will usually suffice. I warmly endorse the excellent 
results which are obtained by this method, under which the patient often 
gains rapidly in weight, and the general health improves remarkably. It 
may be continued for months without any ill effects. Other forms given 
by the mouth are the pilules of the biniodide (gr. -fa), or of the protiodide 
(gr. ^), three times a day. " If mercury be begun as soon as the state of 
the sore permits of diagnosis, and continued in small but adequate doses, 
the patient will usually escape both sore throat and eruption " (J onathan 
Hutchinson). 

Inunction is a still more effective means. A drachm of the ordinary 
mercurial ointment is thoroughly rubbed into the skin every evening for 
six days; on the seventh a warm bath is taken, and on the eighth the mer- 
curial course is resumed. At least half an hour should be given to each 
inunction. It is well to apply it at different places on successive days. 
The sides of the chest and abdomen and the inner surfaces of the arms 
and thighs are the best positions. 

The mercury may be given by direct injection into the muscles. If 
proper precautions are taken in sterilizing the syringe, and if the injec- 
tions are made into the muscles, not into the subcutaneous tissue, abscesses 
rarely result. One third of a grain of the bichloride in twenty drops of 
water may be injected once a week, or from one to two grains of calomel in 
glycerin (20 minims). 

Still another method, greatly in vogue in certain parts of the Continent 
and in institutions, is fumigation. It may be carried out effectively by 
means of Lee's lamp. The patient sits on a chair wrapped in blankets, 
with the head exposed. The calomel is volatilized and deposited with the 
vapor on the patient's skin. The process lasts about twenty minutes, and 
the patient goes to bed wrapped in blankets without washing or drying the 
skin. A patient under mercurial treatment should avoid stimulants and 
live a regular life, not necessarily abstaining from business. Green vege- 
tables and fruit should not be taken. Salivation is to be avoided. The 
teeth should be cleansed twice a day, and if the gums become tender, the 
breath fetid, or the tongue swollen and indented, the drug should be sus- 
pended for a week or ten days. 

In congenital syphilis the treatment of cases born with bullae and other 
signs of the disease is not satisfactory, and the infants usually die within a 
few days or weeks. The child should be nursed by the mother alone, or, 
if this is not feasible, should be hand-fed, but under no circumstances 
should a wet-nurse be employed. The child is most rapidly and thor- 



254 



SPECIFIC INFECTIOUS DISEASES. 



oughly brought under the influence of the drug by inunction. The mer- 
curial ointment may be smeared on the flannel roller. This is not a very 
cleanly method, and sometimes rouses the suspicion of the mother. It 
is preferable to give the drug by the mouth, in the form of gray powder, 
half a grain three times a day. In the late manifestations associated with 
bone lesions, the combination of mercury and iodide of potassium is most 
suitable and is well given in the form of Gilbert's syrup, which consists 
of the biniodide of mercury (gr. j), of potassium iodide ( § ss.), and water 
( 1 ij). Of this a dose for a child under three is from five to ten drops three 
times a day, gradually increased. Under these measures, the cases of con- 
genital syphilis usually improve with great rapidity. The medication 
should be continued at intervals for many months, and it is well to watch 
these patients carefully during the period of second dentition and at 
puberty, and if necessary to place them on specific treatment. 

In the treatment of the visceral lesions of syphilis, which come, more 
distinctly within the province of the physician, iodide of potassium is of 
equal or even greater value than mercury. Under its use ulcers rapidly 
heal, gummatous tumors melt away, and we have an illustration of a spe- 
cific action only equalled by that of mercury in the secondary stages, by 
iron in certain forms of anaemia, and by quinine in malaria. It is as a 
rule well borne in an initial dose of 10 grains, or 10 minims of the saturated 
solution; given in milk the patient does not notice the taste. It should 
be gradually increased to 30 or more grains three times a day. In syphilis 
of the nervous system it may be used in still larger doses. Seguin, who 
specially insisted upon the advantage of this plan, urged that the drug 
should be pushed, as good effects were not obtained with the moderate doses. 

When syphilitic hepatitis is suspected the combination of mercury and 
iodide of potassium is most satisfactory. If there is ascites, Addison's or 
Niemeyer's pill (as it is often called) of calomel, digitalis, and squills will 
be found very useful. A patient of mine with recurring ascites, on whom 
paracentesis was repeatedly performed and who had an enlarged and irregu- 
lar liver, took this pill for more than a year with occasionally intermissions, 
and ultimately there was a complete disappearance of the dropsy and an 
extraordinary reduction in the volume of the liver. Occasionally the iodide 
of sodium is more satisfactory than the iodide of potassium. It is less 
depressing and agrees better with the stomach. Many patients possess a 
remarkable idiosyncrasy to the iodide, but as a rule it is well borne. Severe 
coryza with salivation, and oedema about the eyelids, are its most common 
disagreeable effects. Skin eruptions also are frequent. I have known pa- 
tients unable to take more than from 20 to 30 grains without suffering 
from an erythematous rash; much more common is the acne eruption. 
Occasionally an urticarial rash may develop with spots of purpura. Some 
of these iodide eruptions may closely resemble syphilis. Hutchinson has 
reported instances in which they have proved fatal. 

Upon the question of syphilis and marriage the family physician is 
often called to decide. He should insist upon the necessity of two full 
years elapsing between the date of infection and the contracting of mar- 
riage. This, it should be borne in mind, is the earliest possible limit, and 



GONORRHGEAL INFECTION. 



255 



there should be at least a year of complete immunity from all manifesta- 
tions of the disease. 

In relation to life insurance, an individual with syphilis cannot be re- 
garded as a first-class risk unless he can furnish evidence of prolonged and 
thorough treatment and of immunity for two or three years from all mani- 
festations. Even then, when we consider the extraordinary frequency of 
the cerebral and other complications in persons who have had this disease 
and who may even have undergone thorough treatment, the risk to the 
company is certainly increased. 



XXXIII. GONORRHGEAL INFECTION. 

Gonorrhoea, one of the most widespread and serious of infectious dis- 
eases, presents many features for consideration. As a cause of ill-health 
and disability the gonococcus occupies a position of the very first rank 
among its fellows. While the local lesion is too often thought to be trifling, 
in its singular obstinacy, in the possibilities of permanent sexual damage 
to the individual himself and still more in the " grisly troop " which may 
follow in its train, gonorrhceal infection does not fall very far short of 
syphilis in importance. 

The immediate and remote effects of the gonococcus may be considered 
under — 

I. The primary infection. 

II. The spread in the genito-urinary organs by direct continuity of 
surface. 

III. Systemic gonorrhceal infection. 

I. The primary lesion we need not here consider, but we may call 
attention to the frequency of the complications, such as periurethral ab- 
scess, gonorrhceal prostatitis in the male, and vaginitis, endocervicitis, and 
inflammation of the glands of Bartholini in the female. 

II. Perhaps the most serious of all the sequels of gonorrhoea are those 
which result from the spread by direct continuity of tissue. Gonorrhceal 
salpingitis has been shown to be a not infrequent event. Metritis and 
ovaritis are also occasionally met with, and peritonitis. Young and Cush- 
ing have found the gonococcus in pure culture in two cases of acute general 
peritonitis. Equally important is the development of cystitis, which is 
probably much more frequently the result of a mixed infection than due 
to the gonococcus itself. There is some danger of extension upward through 
the ureters to the kidneys. The pyelitis, like the cystitis, is usually a mixed 
infection. 

III. Systemic Gonorrhceal Infection. 

1. Gonorrhceal Septicemia and Pyaemia. — The fever associated with the 
primary disease is not an indication of a general infection, but probably 
follows the absorption of toxines. The presence of the gonococcus has 
been demonstrated in the blood in a few cases, usually in connection with 
some local lesion, as in Thayer's and Blumer's case from my wards, in 



256 



SPECIFIC INFECTIOUS DISEASES. 



which the patient succumbed to an acute endocarditis. Instances of se- 
vere, rapidly fatal general infection in gonorrhoea are probably always 
associated with foci of suppuration in the urinary tract. I held an autopsy 
in Montreal on a remarkable case of rapid gonorrhceal sepsis in a young 
man, who within ten days of the primary lesion was seized with severe 
chills and high fever. He rapidly became unconscious, the fever persisted, 
and he fell into a condition of profound toxaemia and died early on the 
morning of the fourth day from the chill. At the autopsy, which was made 
about twelve hours after death, there was an acute urethritis and a small 
prostatic abscess not more than 2 or 3 cm. in diameter. The blood was 
fluid, tarry black, and unlike anything I have ever seen before or since. 

Gonorrhceal Endocarditis. — K. L. MacDonnell found 4 cases of endo- 
carditis in 27 instances of gonorrhceal arthritis. Two remarkable cases 
have been reported from my wards lately by Thayer and Blumer and 
Thayer and Lazear. They are of special interest, as in both the gonococci 
were isolated from the blood during life and after death from the affected 
valves. Thayer and Lazear have analyzed 30 instances of fatal ulcerative 
endocarditis in gonorrhoea. Of these, 22 were in men, 8 in women. As a 
rule, the arthritis preceded the cardiac affection, but in a number of in- 
stances the cardiac complication occurred without or before the develop- 
ment o£ joint symptoms. 

Of other cardiac lesions, pericarditis occurred in 7 of the fatal cases. 
Acute myocarditis was present in Councilman's case. 

2. Gonorrhceal Arthritis. — In many respects this is the most damaging, 
disabling, and serious of all the complications of gonorrhoea. Clement 
Lucas has collected 23 cases in children, of which 18 followed ophthalmia 
neonatorum. It occurs more frequently in males than in females. In a 
series of 252 cases collected by Northrup, 230 were in males; 130 cases 
were between twenty and thirty years of age. It occurs, as a rule, during 
an acute attack of gonorrhoea. In 208 of Northrup's series there was a 
urethral discharge while in hospital. It may occur as the attack subsides, 
or even when it has become chronic. A gonorrhceal arthritis of great inten- 
sity may develop in a newly married woman infected by an old gleet in her 
husband. As a rule, many joints are affected. In Northrup's series three 
or more joints were affected in 175 cases, one joint in 56 cases. It is pecul- 
iar in attacking certain joints which are rarely involved in acute rheuma- 
tism, as the sterno-clavicular, the intra-vertebral, the temporo-maxillary 
and sacro-iliac. 

The anatomical changes are variable. The inflammation is often peri- 
articular, and extends along the sheaths of the tendons. When effusion 
occurs in the joints it rarely becomes purulent. It has more commonly 
the characters of a synovitis. About the wrist and hand suppuration gome- 
times occurs in the sheaths. It has been suggested that the simple arthritis 
or synovitis follows absorption of ptomaines from the urethral discharge, 
while the more severe suppurating forms are due to infection with pus or- 
ganisms. It has now been definitely shown that the gonoeoecus itself may 
be present in the inflamed joint or in the peri-arthritic exudate. Within 
the past eighteen months Young has obtained the gonoeoecus in pure cul- 



GONORRHEAL INFECTION. 



257 



ture in 7 cases of gonorrhoeal arthritis in the Johns Hopkins Hospital. 
Sometimes the cultures are negative; in other instances there is a mixed 
infection with staphylococci or streptococci. 

Clinical Course. — Variability and obstinacy are the two most dis- 
tinguishing features. The following are the most important clinical forms: 

(a) Arthralgia, in which there are wandering pains about the joints, 
without redness or swelling. These persist for a long time. 

(b) Poly arthritic, in which several joints become affected, just as in 
subacute articular rheumatism. The fever is slight; the local inflamma- 
tion may fix itself in one joint, but more commonly several become swollen 
and tender. In this form cerebral and cardiac complications may occur. 

(c) Acute gonorrheal arthritis, in which a single articulation becomes 
suddenly involved. The pain is severe, the swelling extensive, and due 
chiefly to peri-articular oedema. The general fever is not at all proportion- 
ate to the intensity of the local signs. The exudate usually resolves, 
though suppuration occasionally supervenes. 

(d) Chronic Hydrarthrosis. — This is usually mono-articular, and is par- 
ticularly apt to involve the knee. It comes on often without pain, redness, 
or swelling. Formation of pus is rare. It occurred only twice in 96 cases 
tabulated by Nolen. 

(e) Bursal and Synovial Form. — This attacks chiefly the tendons and 
their sheaths and the bursae and the periosteum. The articulations may 
not be affected. The bursae of the patella, the olecranon, and the tendo 
Achillis are most apt to be involved. 

(/) Septicemic. — In which with an acute arthritis the gonococci invade 
the blood, and the picture is that of an intense septico-pyaamia, usually 
with endocarditis. 

The disease is much more intractable than ordinary rheumatism, and 
relapses are extremely common. It may become chronic and last for years. 

Complications. — Iritis is not infrequent and may recur with suc- 
cessive attacks. The visceral complications are rare. Endocarditis, peri- 
carditis, and pleurisy may occur. 

Treatment. — The salicylates are of very little service, nor do they 
often relieve the pains in this affection. Iodide of potassium has also proved 
useless in my hands, even in large doses. A general tonic treatment seems 
much more suitable — quinine, iron, and, in the chronic cases, arsenic. 

The local treatment of the joints is very important. The thermo- 
cautery may be used to allay the pain and reduce the swelling. In acute 
cases, fixation of the joints is very beneficial, and in the chronic forms, 
massage and passive motion. I have seen very good results follow in a few 
cases the use of the dry hot air. The surgical treatment of this affection, 
as carried out nowadays, is more satisfactory, and I have seen strikingly 
good effects from incision and irrigation. 



258 



SPECIFIC INFECTIOUS DISEASES. 



XXXIV. TUBERCULOSIS. 

I. Genebal Etiology axd Morbid Anatomy. 

Definition. — An infective disease, caused by Bacillus tuberculosis, the 
lesions of which are characterized by nodular bodies called tubercles or 
diffuse infiltrations of tuberculous tissue which undergo caseation or scle- 
rosis and may finally ulcerate, or in some situations calcify. 

Etiology.— 1. Zoological Distribution.— Tuberculosis is one of the 
most widespread of maladies. 

In cold-blooded animals it is rare, owing doubtless to temperature con- 
ditions unfavorable to the development of the bacillus. Among reptiles 
in confinement it is, however, occasionally seen (Sibley). In fowls it is an 
extremely common disease, but there are differences in avian tuberculosis 
sufficient to warrant its separation from the ordinary form. 

Among domestic animals tuberculosis is widely but unevenly distrib- 
uted. Among ruminants, bovines are chiefly affected. The percentage 
for oxen and cows at the Berlin abattoir in the year 1892-93 was 15.1. In 
this country much has been done, particularly in Massachusetts and Penn- 
sylvania, to determine the presence of the disease in the dairy herds, for 
which purpose the tuberculin test has been extensively employed. The 
results show a widespread prevalence of the disease. 

Of 5,297 cattle slaughtered in Maryland only 159 were tuberculous 
(A. W. Clement). Of 15,506 slaughtered at the Brighton abattoir, Boston, 
only 29 were tuberculous (A. Burr). The tuberculin test has shown in 
some places a percentage of from 15 to 30. 

In sheep the disease is very rare. In pigs it is frequent, but not so 
common in this country as in Europe. In the inspection of 1,000 hogs, 
which was made by A. W. Clement and myself in Montreal in 1880, tuber- 
culosis was seen only once or twice. At the Berlin abattoir in 1887-'S8 
there were 6,393 pigs affected with the disease. 

Horses are rarely attacked. Dogs and cats are not prone to the disease, 
but cases are described in which infection of pet amrnals has taken place 
from phthisical masters. Among the semi-domestic animals, such as the 
rabbit and guinea-pig, the disease under natural conditions is rare, al- 
though these animals, particularly the latter, are extremely susceptible to 
the disease when inoculated. Among apes and monkeys in the wild state, 
tuberculosis is unknown, but in confinement it is the most formidable dis- 
ease with which they have to contend. 

The important etiological fact in connection with tuberculosis in ani- 
mals is the widespread occurrence of the disease in bovines, from which 
class we derive nearly all the milk and a very large proportion of the meat 
used for food. 

2. General Statistics of the Disease in Man. — Tuberculosis is the most 
universal scourge of the human race. It prevails more particularly in the 
large cities and wherever the population is massed together. One seventh 
of all deaths are due to it. In the United States Census Beport for 1890, 
102,188 deaths were reported to be due to consumption. At a low esti- 



TUBERCULOSIS. 



259 



mate one can say that at least 150,000 persons die annually in the United 
States of some form of tuberculosis. An estimation based on the Census 
Eeport gives the total number of persons in this country infected with 
tuberculosis as 1,050,000, or 1 in every 60 of the population (Vaughan). 

Geographical position has very little influence. The disease is perhaps 
more prevalent in the temperate regions than in the tropics, but altitude 
is a more potent factor than latitude; in the high regions of the Alps and 
Andes and in the central plateau of Mexico the death-rate from tubercu- 
losis is very low. 

The influence of race, which has been much studied, is probably less 
owing to any inherent differences than to the conditions under which the 
individuals live. The Indians of this continent are very prone to the dis- 
ease. Matthews states that the death-rate in the older reservations in the 
East was three times as great as that of the Indians still living in the 
Northwest. In this country the Irish and the negroes appear specially 
prone to the disease; on the other hand, the Hebrews possess a relative 
immunity. For the six years ending May 31, 1890, the average annual 
death-rate "from consumption in New York city per 100,000 of population 
was: For the Irish, 645.73; for the colored, 531.35; for the Germans, 
328.80; for the American whites, 205.14; and for the Kussian-Polish Jews, 
76.72. In this city the disease prevails extensively among the Eussian 
Jews. 

The Decrease of Tuberculosis. — E. F. Wells, who has tabulated an im- 
mense body of statistics on this subject, states that the evidence is in favor 
of a very positive decline in the prevalence of the disease. While the last 
decennial census of the United States does not show any decrease, yet in 
many of the larger cities there has been a striking diminution. The ques- 
tion has been considered very carefully by James B. Eussell, of Glasgow, in 
his Sanitary History of that city. One or two of the sentences from his re- 
port may be quoted with advantage: " Between the five years 1870-'74 and 
the five years 1890-'94 there was a decrease of 41 per cent in the death-rate. 
If we start from the maximum period of fatality (1860-'64), the decrease 
amounts to 44 per cent. The acceptance of the doctrine that every case 
of phthisis is the result of a specific infection — that, consequently, no one 
is foredoomed to have phthisis or any other form of tuberculous disease — 
gives great precision to our ideas of prevention." He attributes a good 
deal to the diffusion of the knowledge that the existence and distribution of 
the tubercle bacillus are the first conditions of infection, and also to the suc- 
cessful administrative efforts in securing * ventilation, especially of houses 
and byres; the removal of dampness by subsoil drainage and precautions 
adapted to the foundations and walls of houses; the abolition of dark spaces 
and inclosures; the dissemination of direct sunlight." 

The diminution of pulmonary tuberculosis in Massachusetts is remark- 
able, the death-rate having fallen from 42 per 10,000 inhabitants in 1853 
to 21.8 per 10,000 in 1895. A remarkable reduction has also taken place in 
New York and in London (Beevor). 

3. Bacillus Tuberculosis. — Eegarded as contagions in olden time, and 
always in certain countries, Villemin first placed the infective nature of 
tuberculosis on a solid experimental basis. Cohnheim and Salamonson 



260 



SPECIFIC INFECTIOUS DISEASES. 



confirmed his results. Finally, after years of work, came the isolation of 
the tubercle bacillus by Koch, who demonstrated its invariable association 
with the disease. The investigations which he had previously made upon 
anthrax and experimental traumatic infections, by perfecting the methods 
of research, paved the way for this brilliant discovery. His preliminary 
article * and his more elaborate later work f should be carefully studied by 
any one who wishes to appreciate the value of scientific methods. It forms 
one of the most masterly demonstrations of modern medicine. Its thor- 
oughness appears in the fact that in the years wdiich have elapsed since its 
appearance the innumerable workers on the subject have not, so far as 
I know, added a solitary essential fact to those presented by Koch. 

Morphological Characters. — The tubercle bacillus occurs usually as a 
short, fine rod, often slightly bent or curved, and has an average length of 
nearly half the diameter of a red blood-corpuscle (3 to 4 ft); more rarely it 
shows lateral outgrowths or simple branches. When stained it often presents 
a beaded appearance, which some have attributed to the presence of spores. 

With the basic aniline dyes it stains slowly, except at the body tem- 
perature, but retains the dye after treatment with acids — a characteristic 
which separates it from all other known forms of bacteria, with the excep- 
tion of the bacillus of leprosy. 

Modes of Growth. — It grows on blood-serum, glycerin-agar, bouillon, or 
on potato — most readily on the first. The cultures must be kept at blood- 
heat. They grow slowly, and do not appear until about the end of the 
second week. The colonies form thin, grayish-white, dry, scale-like masses 
on the surface of the culture medium. Successive inoculations may be 
made from the cultures, and at the end of an indefinite series material 
from one of them inoculated into a guinea-pig will produce tuberculosis. 

Variations. — (a) In Form. — The small branching forms are found not 
infrequently in tuberculous lesions. Some investigators claim to have pro- 
duced more complex structures, resembling the " Driisen " of the actino- 
myces. 

(b) In Virulence. — Koch was of the opinion that tubercle bacilli from 
various sources possess the same degree of virulence. Theobald Smith has 
found cultures of bovine tuberculosis more highly virulent for rabbits 
than cultures of sputum bacilli. The morphology of the organisms from 
the two sources was also different. Arloing and his students have long 
claimed that material from scrofula and bone tuberculosis is less virulent 
than from other varieties of human tuberculosis. 

Bacillus tuberculosis avium tends to appear in more irregular forms, 
grows more readily and more rapidly in artificial cultures, and is more re- 
sistant to age and high temperature, and, while highly pathogenic for the 
hen, produces only local inflammatory processes in mammals. It is probable 
that infection with avian tuberculosis sometimes occurs in man (Pausini). 

Composition and Products. — Tubercle bacilli contain water, various pro- 
teids, fats (to which the peculiar staining reaction is due), a carbohydrate 



* Berliner klinische Wochensehrift, 1882. 

f Mittheilungen a. d. k. Gesundheitsamte, Bd. 2. 



TUBERCULOSIS. 



261 



resembling glycogen, cellulose, free and combined nucleic acid, and ash 
(P. A. Levene). Koch's tuberculin is a proteid glycerin extract from the 
bacilli. 

Distribution of the Bacilli. — The bacilli are found in all tuberculous 
lesions; in some in great abundance, in others sparsely. They are par- 
ticularly numerous in actively developing tubercles, but in the chronic 
tuberculous processes of lymph-glands and of the joints they are scanty. 
When a tuberculous focus communicates with a vein or with lymph-ves- 
sels, the bacilli may be spread widely throughout the body. In old lesions 
they may not be found in the sections, and the demonstration of the true 
nature may be possible only by culture or inoculation. 

The Bacilli outside the Body. — Patients with advanced pulmonary 
tuberculosis throw off in the expectoration countless millions of the bacilli 
daily. Some idea of the extraordinary numbers may be gained from the 
studies of Nuttall. From a patient with moderately advanced disease, 
the amount of whose expectoration was from 70 to 130 cc. daily, he esti- 
mated by his method that there were in sixteen counts, between January 
10th and March 1st, from one and a half to four and a third billions of 
bacilli thrown off in the twenty-four hours. These figures emphasize the 
danger associated with phthisical sputa unless most carefully dealt with. 
When expectorated and allowed to dry, the sputum rapidly becomes dust, 
and is distributed far and wide. The observations made by Cornet under 
Koch's supervision are in this connection most instructive. He collected 
the dust from the walls and bedsteads of various localities, and determined 
its virulence or innocuousness by inoculation into susceptible animals. 
Material was gathered from 21 wards of 7 hospitals, 3 asylums, 2 prisons, 
from the surroundings of 62 phthisical patients in private practice, and 
from 29 other localities in which tuberculous patients were only transient 
frequenters (out-patient departments, streets, etc.). Of 118 dust samples 
from hospital wards or the rooms of phthisical patients, 40 were infective 
and produced tuberculosis. Negative results were obtained with the 29 
dust samples from the localities occasionally occupied by consumptives. 
Virulent bacilli were obtained from the dust of the walls of 15 out of 21 
medical wards. It is interesting to note that in 2 wards with many phthis- 
ical patients the results were negative, indicating that the dust in such 
regions is not necessarily infective. The infectiousness of the dust of the 
medical and surgical divisions of a hospital is in the proportion of 76.6 to 
12.5. In a room in which a tuberculous woman had lived the dust from 
the wall in the neighborhood of the bed was infective six weeks after her 
death. No bacilli were found in the dust of an inhalation-chamber for 
consumptives. The experiments of Strauss at the Charite Hospital, Paris; 
are important. In the nostrils of 29 assistants, nurses, and ward-tenders 
he placed pings of cotton-wool to collect the dust of the wards. In 9 of 
the 29 cases these contained tubercle bacilli and proved infective to ani- 
mals. The question of the increase of tuberculosis among the permanent 
residents of health resorts frequented by consumptives is one of great 
interest. Gardiner has studied the problem at Colorado Springs, in 
which for twenty years tuberculous patients have been living, and he 



262 



SPECIFIC INFECTIOUS DISEASES. 



finds the number of cases of tuberculosis originating in the city to be very 
small. 

Pseudo-tuberculosis. — While lesions resembling the nodules of tubercu- 
losis, but due to a variety of bacteria, protozoa, and nematodes, are not un- 
common in animals, pseudo-tuberculous processes are very rare in human 
beings. Flexner * has described, under the name pseudo-tuberculosis 
hominis streptothrica, a condition in human beings in which the lungs pre- 
sented the appearance of a caseous pneumonia and numerous tubercle-like 
nodules existed in the peritonaeum. The micro-organism found in the 
lesions was a streptothrix, which differed greatly from the known forms 
of the bacillus tuberculosis and streptothrix actinomyces. 

4. Modes of Infection. — (a) Hereditary Transmission. — The possible 
methods of transmission of the germ in direct inheritance are 'three — 
transmission by the sperm, transmission by the ovum, and transmission 
through the blood by means of the placenta. 

There is no clinical evidence to support the view that direct transmis- 
sion can occur through the sperm. In order that the disease could be trans- 
mitted by the sperm it would be necessary that the tubercle bacilli should 
lodge in the individual spermatozoon which fecundates the ovum. The 
chances that such a thing could occur are extremely small, looking at the 
subject from a numerical point of view, although we know that tubercle 
bacilli do occasionally exist in the semen; they become still smaller when 
we consider that the spermatozoon is made up of nuclear material, which 
the tubercle bacillus is never known to attack. Experimentation is all 
opposed to sperm transmission, the work of Gartner and others showing 
that the young of healthy female rabbits impregnated by tuberculous males 
are never tuberculous, even though the females themselves often contract 
the disease. 

The possibility of transmission by the ovum must be accepted. Baum- 
garten has in one instance been able to detect the tubercle bacillus in the 
ovum of a female rabbit which he had artificially fecundated with tubercu- 
lous semen. The work of Pasteur on pebrine has shown the possibility of 
this form of transmission in the lower forms, though the question as to 
what effect such inoculation would have upon the human ovum cannot of 
course be answered. 

Probably the almost constant method of transmission in congenital 
tuberculosis is through the blood current, the tubercle bacilli penetrating 
by way of the placenta. Certain authors hold that in these cases the pla- 
centa itself is invariably the seat of tuberculosis, and tubercles, indeed, 
have been demonstrated in several cases; but there are undoubted instances 
in which, with an apparently sound placenta, both the placental blood and 
the foetal organs contained tubercle bacilli, notwithstanding the fact that 
the organs also appeared normal. 

Possible Latency of the Tubercle Germs. — Baumgarten and his followers 
•assume that the tubercle bacilli can lie latent in the tissues and subse- 
quently develop when, for some reason or other, the individual resistance 



* Journal of Experimental Medicine, 1898. 



TUBERCULOSIS. 



263 



is lowered. He likens such cases of latent tuberculosis to the late heredi- 
tary forms of syphilis, and explains the lack of development of the germs 
by the greater resisting power of the tissues of children. In the discussion 
on latency before the Royal Medical and Chirurgical Society of London, 
Kingston Fowler expressed the sensible opinion that it was not necessary 
seriously to consider the question of latency in tuberculosis until direct 
transmission from mother to child was proved to be of frequent occur- 
rence. Baumgarten bases his belief in germ transmission upon two main 
factors — the great frequency of the disease in early life and the localization 
of tuberculous lesions in children. 

The mortality from tuberculosis in the first years of life is relatively 
high. Of 2,576 autopsies made on children, 27.8 per cent who died in the 
first year were tuberculous (Botz). Of 182 autopsies on children one year 
or under, 17 were tuberculous (Comby). The localization of tuberculous 
lesions in children in the bones or joints is very common, Cnopp's sta- 
tistics showing that out of 298 tuberculous children of from a few days 
to twelve years of age, 147 had bone or joint tuberculosis, and only 8 of 
these showed evidence of visceral disease. Baumgarten is of the opinion 
that the accidental conveyance of tubercle bacilli to these points would not 
account for such a large proportion of cases, and expresses the view that 
the bacilli have been present since birth and have developed when favor- 
able conditions offered. The evidence in favor of Baumgarten's view is 
both clinical and experimental. 

The clinical evidence exists in the form of undoubted cases of con- 
genital tuberculosis, of which there are now, in man alone, about 20 ex- 
amples in the literature; besides these, a number of spontaneous cases of 
congenital tuberculosis in the lower animals have been reported. 

A number of laboratory workers have been able to show that congenital 
tuberculosis can be produced experimentally, the most prominent of these 
being Gartner, who was able to cause tuberculosis in young mice by inocu- 
lating the mother with tuberculosis, either into the peritoneal cavity or 
into the blood stream. Mafucci has shown that after injecting eggs with 
avian tuberculosis the disease may remain latent in the chick for weeks or 
even months. 

Against Baumgarten's theory are the facts that the percentage of cases 
of congenital tuberculosis is extremely small, and that in the great majority 
of instances the organs of foetuses born of tuberculous mothers give nega- 
tive results when inoculated into guinea-pigs. 

No circumstance, perhaps, has contributed more to the belief in the 
hereditary transmission of the disease than the frequency with which tuber- 
culosis is met with in the ascendants of those affected. The estimates range 
from 10 per cent to 25 per cent, or even in some instances to 50 per cent. 
Some of the statistics on this point are worth quoting: In 1,000 cases Wil- 
liams found 48.4 per cent with family predisposition, 12 per cent with 
parental, 1 per cent with grandparental, and 34.4 per cent with collateral 
heredity. Of 250 cases in which Solly made very careful inquiries on this 
point, there were 28.8 per cent with parental, 7.6 per cent with grand- 
parental, and 19.2 per cent with a history of collateral heredity. Of 427 



264 



SPECIFIC INFECTIOUS DISEASES. 



cases at the Johns Hopkins Hospital, there were 53 in which the mother 
had had tuberculosis, 52 in which the father had been affected, and 105 in 
which a brother or sister had had the disease. The question of family in- 
fection is the all-important one, and Hilton Fagge very wisely remarks that 
it is impossible to draw a line between hereditary and accidental tubercu- 
losis, as naturally the children of an affected parent are more liable to acci- 
dental contamination. In a recent careful study of heredity in phthisis, 
Squire concludes that there is but a small difference between the incidence 
of the disease in the offspring of phthisical and non-phthisical parents. 

While the demonstration of the contagiousness of tuberculosis has in 
some quarters intensified the dread with which the disease is regarded, 
the terrible Ate of hereditary transmission has been in great part abolished, 
to the great gain of suffering humanity. 

(b) Inoculation. — The infective nature of tuberculosis was first demon- 
strated by Yillemin, who showed conclusively in 1865 that it could be trans- 
mitted to animals by inoculation. The beautiful experiments of Cohnheim 
and Salamonson, who produced tuberculosis in the eyes of guinea-pigs and 
rabbits by inoculating fresh tubercle into the anterior chamber, confirmed 
and extended Yillemin's original observations and paved the way for the 
reception of Koch's announcement. It is now universally conceded that 
only tuberculous matter can produce, when inoculated, tuberculosis. In 
man tuberculosis is not often transmitted by inoculation, and when it does 
occur the disease usually remains local. This mode of infection is seen in 
persons whose occupation brings them in contact with dead bodies or ani- 
mal products. Demonstrators of morbid anatomy, butchers, and handlers 
of hides are subject to a local tubercle of the skin, which forms a reddened 
mass of granulation tissue, usually capping the dorsal surfaces of the hands 
or fingers. This is the so-called post-mortem wart, the verruca necrogenica 
of Wilks. The demonstration of its nature is shown by the presence of 
tubercle bacilli, and by inoculation experiments in animals. 

The statement that Laennec contracted phthisis from this source is 
probably false, since he did not die until twenty years after the inocula- 
tion and in the interval presented no manifestations. The possibility, how- 
ever, of general infection must be borne in mind. Gerber reports that 
after accidental inoculation in the hand from a case of phthisis he had 
for months a " Leichen-tubercle," which was excised. Shortly afterward 
the lymph-glands of the axilla became enlarged and painful, and when re- 
moved showed characteristic tuberculous changes, with bacilli. 

In the performance of the rite of circumcision children have been acci- 
dentally inoculated. Infection in these cases is probably always associated 
with disease in the operator, and occurs in connection with the habit of 
cleansing the wound by suction. 

Other means of inoculation have been described: as the wearing of 
ear-rings, washing the clothes of phthisical patients, the bite of a tubercu- 
lous subject, or inoculation from a cut by a broken spit-glass of a consump- 
tive; and Czerny has reported two cases of infection by transplantation of 
skin. 

It has been urged by the opponents of vaccination that tuberculosis, as 



TUBERCULOSIS. 



265 



well as syphilis, may be thus conveyed, but of this there is no evidence. 
Lymph of revaccinated consumptives is non-infective. Lupus has origi- 
nated at the site of vaccination in a few cases (C. Fox, Graham Little). It 
may be said, on the whole, that inoculation in man plays a trifling role in 
the transmission of tuberculosis. 

(c) Infection by Inhalation. — A belief in the contagiousness of pul- 
monary tuberculosis has existed from the days of the early Greek physi- 
cians, and has persisted among the Latin races. The investigations of 
Cornet afford conclusive proof that the dust of a room or other locality 
frequented by patients with pulmonary tuberculosis is infective. The 
bacilli are attached to fine particles of dust and in this way gain entrance 
to the system through the lungs. 

Fliigge denies that the bacillus-containing dust is the dangerous ele- 
ment in infection. Experimentally he has only succeeded in producing 
the disease when there is some lesion in the respiratory tract. He thinks 
that the danger of infection by the dry sputum is very improbable. On 
the other hand, he thinks that the infection is chiefly conveyed by the free, 
finely divided particles of sputum produced in the act of coughing, and 
that these tiny fragments are suspended in the atmosphere. Those who 
cough very much and with the mouth open are most liable to infect the 
surrounding air. 

It is well remarked by Cornet, " The consumptive in himself is almost 
harmless, and only becomes harmful through bad habits/' It has been 
fully shown that the expired air of consumptives is not infective. The 
virus is only contained in the sputum, which when dry is widely dissemi- 
nated in the form of dust, and constitutes the great medium for the trans- 
mission of the disease. " In order to be air-borne the sputum must be 
dried and broken up into dust. If discharged into a handkerchief, it 
speedily dries, especially if it is put into the pocket or beneath the pillow. 
In the last stages of consumption the patient becomes weak, the sputum 
is expelled imperfectly, pillows, sheets, and handkerchiefs are soiled. If a 
male, the beard or moustache is smeared. Even in the hands of the cleanly, 
without special precautions, such circumstances all tend to the production 
around the patient of a halo of infected dust maintained by every process 
of bedmaking or of cleaning which includes the pernicious process happily 
described as ' dusting/ In the hands of the careless and the dirty the in- 
fectivity is, of course, greatly aggravated. It attains its maximum of in- 
tensity where the filthy habit of spitting on the floor prevails, especially 
if it is carpeted " (James B. Russell). 

The following are some of the facts in favor of infection by inhala- 
tion: 

(1) Primary tuberculous lesions are in a majority of all cases connected 
with the respiratory system. The frequency with which foci are met with 
in the lungs and in the bronchial glands is extraordinary, and the statis- 
tics of the Paris morgue show that a considerable proportion of all persons 
dying of accident or by suicide present evidences of the disease in these 
parts. The post-mortem statistics of hospitals show the same widespread 
prevalence of infection through the air-passages. Biggs reports that more 



266 



SPECIFIC INFECTIOUS DISEASES. 



than 60 per cent of his post mortems showed lesions of pulmonary tuber- 
culosis. In 125 autopsies at the Foundling Hospital, New York, the bron- 
chial glands were tuberculous in every case. In adults the bronchial glands 
may be infected and the individual remain in good health. H. P. Loomis 
found in 8 of 30 cases in which there were no signs of old or recent tuber- 
culous lesions that the bronchial glands were infective to rabbits. 

(2) The greater prevalence of tuberculosis in institutions in which the 
residents are confined and restricted in the matter of fresh air and a free 
open life — conditions which would favor, on the one hand, the presence 
of the bacilli in the atmosphere, and, on the other, lower the vital resist- 
ance of the individual. The investigations of Cornet upon the death-rate 
from consumption among certain religious orders devoted to nursing give 
some striking facts in illustration of this. In a review of 38 cloisters, em- 
bracing the average number of 4,028 residents, among 2,099 deaths in the 
course of twenty-five years, 1,320 (62.88 per cent) were from tuberculosis. 
In some cloisters more than three fourths of the deaths are from this dis- 
ease, and the mortality in all the residents, up to the fortieth year, is greatly 
above the average, the increase being due entirely to the prevalence of 
tuberculosis. It has been stated that nurses are not more prone to the dis- 
ease than other individuals, but Cornet says that of 100 nurses deceased, 63 
died of tuberculosis. The more perfect the prophylaxis and hygienic ar- 
rangements of an asylum or institution, the lower the death-rate from 
tuberculosis. The mortality in prisons has been shown by Baer to be 
four times as great as outside. The death-rate from phthisis is estimated 
at 15 per cent of the total mortality, while in prisons it constitutes from 40 
to 50 per cent, and in some countries, as Austria, over 60 per cent. Flick 
has studied the distribution of the deaths from tuberculosis in a single 
city ward in Philadelphia for twenty-five years. His researches go far to 
show that it is a house disease. About 33 per cent of infected houses have 
had more than one case. Less than one third of the houses of the ward 
became infected with tuberculosis during the twenty-five years prior to 
1888. Yet more than one half of the deaths from this disease during the 
3'ear 1888 occurred in those infected houses. There are, however, opposing 
facts. The statistics of the Brompton Consumption Hospital show that 
doctors, nurses, and attendants are rarely attacked. Dettweiler claims that 
no case of tuberculosis has been contracted among his nurses or attendants 
at Falkenstein. On the other hand, in the Paris hospitals tuberculosis 
decimates the attendants. 

(3) Special danger exists when the contact is very intimate, such, for 
instance, as between man and wife. On this point much difference of 
opinion exists, but the figures seem to indicate that under these circum- 
stances the husband or wife is much more liable subsequently to die of 
consumption. Of 427 cases of pulmonary tuberculosis at the Johns Hop- 
kins Hospital, in 25 either husband or wife had been affected with it or 
had died of tuberculosis. In response to a question as to contagion, asked 
by the Collective Investigation Committee of the British Medical Associa- 
tion, there were 261 replies in the affirmative, among which were 158 cases 
of supposed contagion through marriage. Weber's cases are of special in- 



TUBERCULOSIS. 



267 



terest. One of his patients lost four wives in succession, one lost three, 
and four lost two each. 

(d) Infection by Milk. — The milk of an animal suffering from tuber- 
culosis may contain the virus, and is capable of communicating the dis- 
ease, as shown by Gerlach, Bang, Bollinger, and others. Striking illustra- 
tions of this are sometimes afforded in the lower animals. The pigs, for 
instance, of a tuberculous sow have been shown to present intestinal tuber- 
culosis of the most exquisite form. Of late years the experimental proof 
has been entirely conclusive. It was formerly thought that the cow must 
present tuberculous disease of the udder, but Ernst has shown that the 
bacilli may be present and the milk be infective in a large proportion of 
cases in which there is no tuberculous mammitis; an observation made also 
by Hirschberger and others. This author states the interesting fact that 
an owner of a herd, known to be tuberculous withdrew the milk from 
market and used it without boiling to fatten his pigs, which, almost with- 
out exception, became tuberculous, so that the whole stock had to be 
slaughtered. Sidney Martin could not induce the disease artificially in 
animals inoculated or fed with milk of tuberculous cows with healthy 
udders. Butter made from the milk of tuberculous cows has proved in- 
fective (Bang). There is no reason to believe that young children, or 
even adults, are less susceptible to the virus than calves or pigs, so that the 
danger of the disease from this source is real and serious. The great fre- 
quency of intestinal and mesenteric tuberculosis in children no doubt finds 
here its explanation. As noted in Woodhead's analysis of 127 cases of fatal 
tuberculosis in children, the mesenteric glands were involved in 100. 

(e) Infection by Meat. — The meat of tuberculous animals is not neces- 
sarily infective. The results of experiments with the flesh of cows are 
not in accord. This mode of infection probably plays a minor role in the 
etiology of human tuberculosis, as usually the flesh is thoroughly cooked 
before eating. The possibility, however, must be borne in mind, and it 
would certainly be safer in the interests of a community to confiscate the 
carcasses of all tuberculous animals. Experiments in Bollinger's labora- 
tory show that the flesh of tuberculous subjects is very infective to guinea- 
pigs. Martin suggests that when the meat is infective it commonly ac- 
quires this property by accidental contamination with tuberculous matter 
during its removal. 

5. Conditions Influencing Infection. — (a) General. — Environment is an 
all-important -predisposing factor. Dwellers in cities are much more prone 
to the disease than residents of the country. Not only is the liability to 
infection very much greater, but the conditions of life are such that the 
powers of resistance are apt to be weakened. As already stated, sunlight 
is one of the most powerful agents in destroying the tubercle bacillus, so 
that in imperfectly ventilated dwellings and workshops, and in residences 
in close, dark alleys, and in tenement houses the liability to infection is 
very much increased. The influence of environment was never better 
demonstrated than in the now well-known experiment of Trudean, who 
found that rabbits inoculated with tuberculosis if confined in a dark, dam]) 
place without sunlight and fresh air rapidly succumbed, while of hers 
17 



268 



SPECIFIC INFECTIOUS DISEASES. 



treated in the same way, but allowed to run wild, either recovered or showed 
very slight lesions. The occupants of prisons, asylums, and poorhouses, 
too often, indeed, in barracks and large workshops, are in the position of 
Trudeau's rabbits in the cellar, and under conditions most favorable to 
foster the development of the bacilli which may have lodged in their tissues. 
The frequent respiration of air already breathed, upon which MacCormao 
of Belfast laid so much stress, appears to render the lungs less capable of 
resisting infection. 

Soil and locality are believed by many to have a very important bearing 
on the development of tuberculosis. The observations of Henry I. Bow- 
ditch in this country and of Buchanan in England show that the disease 
prevails more widely in the wet, ill-drained districts — an increase which is 
associated with heightened vulnerability and greater liability to catarrhal 
affections of all kinds. The influence of the dwelling has been already 
referred to in connection with Flick's work. No single condition is of 
greater importance than that which relates to the proper arrangement and 
ventilation of the dwelling houses. 

(b) Individual .Predis position. — The fathers of medicine, more particu- 
larly Hippocrates, Aretaeus, and Galen, laid great stress upon the bodily 
conformation of those prone to consumption. A great deal was written 
on the so-called habitus plithisicus, which Hippocrates described in the fol- 
lowing terms: "The form of body peculiar to subjects of phthisical com- 
plaints was the smooth, the whitish, that resembling the lentil; the red- 
dish, the blue-eyed, the leuco-phlegmatic; and that with the scapulae hav- 
ing the appearance of wings." Undoubtedly the long, narrow, flat chest 
with depressed sternum is commonly enough seen in tuberculous patients, 
but there are only too many individuals with perfectly well-shaped chests 
who fall victims annually to the disease. The tuberculous or scrofulous 
diathesis, upon which formerly so much stress was laid, is now regarded 
simply as an indication of a type of conformation in which the tissues are 
more vulnerable and less capable of resisting infection. Beneke's investi- 
gations on the viscera of phthisical patients indicate that the heart is rela- 
tively small, the arteries proportionately narrow, and the pulmonary artery 
relatively wider than the aorta. He suggests that this may lead to increase 
in the intrapulmonary blood pressure, and so favor catarrhal processes. 
The lung volume he found relatively greater in those affected with tubercu- 
losis. A study of the composite portraiture of pulmonary tuberculosis has 
been made by Galton and Mahomed. In 442 patients they separated two 
types of face — one ovoid and narrow, the other broad and coarse-featured. 
This corresponds in an interesting way to the diathetic states formerly 
recognized — namely, the tuberculous, with thin skin, bright eyes, oval face, 
and long, thin bones; and the scrofulous, with thick lips and nose, opaque 
skin, large, thick bones, and heavy figure. These conditions, on which so 
much stress was formerly laid, indicate, as Fagge states, nothing more than 
delicacy of constitution, incomplete growth, and imperfect development. 

(c) Influence of Age. — No age is exempt. The disease is met with in 
the suckling and in the octogenarian. Pulmonary tuberculosis occurs most 
frequently, as stated by Hippocrates, from the eighteenth to the thirty- 



TUBERCULOSIS. 



269 



fifth year. From the fifth to the tenth year individuals are less prone to 
the disease. At different ages different organs are more prone to be in- 
volved. During the first decade the bones, meninges, and lymph-glands 
are more frequently affected than at subsequent periods. 

(d) Sex. — The influence of sex is very slight. Women are perhaps 
somewhat more frequently attacked than men, possibly from the fact 
that in a more sedentary, indoor life they are more liable to infection. 
Pregnancy and lactation also are two conditions which are apt to lower, 
perhaps, the resistance of the organism. 

(e) Race. — The negro, who it is stated is not specially prone to the dis- 
ease in Africa, is in America and in the West Indies very subject to tuber- 
culosis. The relative immunity of the Jews has been mentioned (page 
259). 

(/) Occupation is an important predisposing factor. The inhalation 
of impure air in occupations associated with a very dusty atmosphere 
renders the lungs less capable of resisting infection. The incidence of 
pulmonary tuberculosis among the workers in mills and factories is very 
high, and certain occupations, such as those of glass-workers, stone-cutters, 
and coal-miners, and the whole group of trades, which lead to pneumono- 
koniosis, favor the development of tuberculosis. 

(g) Certain local conditions influence infection, among which the fol- 
lowing are the most important: 

Catarrhal bronchitis. The influence of catarrh of the respiratory pas- 
sages in pulmonary tuberculosis is well recognized. How often is a neg- 
lected cold blamed as the starting-point of the disease! It seems to act 
by lowering the resistance and favoring the conditions which enable the 
bacilli either to enter the system or, when once in it, to develop. The 
liability of lymphatic tuberculosis in children is probably associated with 
the common catarrhal processes in the tonsils, throat, and bronchi. 

Certain of the specific fevers predispose to tuberculosis, among which 
measles and whooping-cough stand pre-eminent. They are often associ- 
ated with a bronchial catarrh. In some of the cases it is probably not a 
fresh infection which follows, but the blazing of a smouldering fire. Ty- 
phoid fever is thought by some to predispose to tuberculosis, but my experi- 
ence is opposed to this view. Of other affections, influenza, variola, and 
syphilis are all believed to favor the development of the disease. Diabetes, 
as is well known, very often terminates in pulmonary tuberculosis, par- 
ticularly in young persons. 

Chronic heart-disease, arterio-sclerosis, aneurism of the aorta, forms of 
chronic nephritis, cirrhosis of the liver, and the various forms of cerebro- 
spinal sclerosis, all are conditions which favor infection. It is remarkable 
in how many of the subjects of these disorders in general hospital practice 
the fatal event is a terminal acute tuberculosis, most frequently of the 
M inus membranes. Subjects of congenital or acquired contraction of the 
orifice of the pulmonary artery usually die of tuberculosis. On the other 
hand, mitral valve disease, particularly stenosis, is stated to antagonize the 
disease (J. E. Graham). In children catarrhal entero-colitis probably favors 
the development of tabes mesenterica. 



270 



SPECIFIC INFECTIOUS DISEASES. 



The influence of haemoptysis and pleurisy will he referred to later. 

Trauma. — The relation of injury to tuberculosis is well known. A blow 
upon the chest may cause a pulmonary or pleural tuberculosis; injury to 
the knee, a tuberculous arthritis; a blow on the head, tuberculous meningi- 
tis. Probably in these cases the injured part is for a time a locus minoris 
resistentice, and if bacilli are present they may receive a stimulus to growth 
or under the altered conditions become capable of multiplying. Mendels- 
sohn reports 9 cases in which, without fracture of the rib or laceration of 
the lung, tuberculosis developed shortly after contusion of the chest. The 
whole question is very fully discussed by Stern in his recent work on the 
relation of internal disease to injury, already referred to in the section on 
Pneumonia. The relation of surgical intervention in local tuberculosis to 
the generalization of the disease is important. An existing lesion may be 
aggravated, and fresh local lesions may appear, and, most serious of all, 
acute miliary tuberculosis may follow. 

General Morbid Anatomy and Histology of Tuberculous 
Lesions. 

(1) Distribution of the Tubercles in the Body. — The organs of the 
body are variously affected by tuberculosis. In adults, the lungs may be 
regarded as the seat of election; in children, the lymph-glands, bones, and 
joints. In 1,000 autopsies there were 275 cases with tuberculous lesions. 
With but two .or three exceptions the lungs were affected. The distribu- 
tion in the other organs was as follows: Pericardium, 7; peritonaeum, 36: 
brain, 31; spleen, 23; liver, 12; kidneys, 32; intestines, 65; heart, 4; and 
generative organs, 8. 

The tuberculosis which comes under the care of the surgeon has a dif- 
ferent distribution, as shown by the following figures from the Wiirzburg 
clinic. Among 8,873 patients, 1,287 were tuberculous, with the following 
distribution of lesions: Bones and joints, 1,037; lymph-glands, 196; skin 
and connective tissues, 77; mucous membranes, 10; genito-urinary or- 
gans, 20. 

(2) The Changes produced by the Tubercle Bacilli. 

(a) The Nodular Tubercle. — The body which we term a "tubercle" 
presents in its early formation nothing distinctive or peculiar, either in its 
components or in their arrangement. Identical structures are produced by 
other parasites, such as the actinomyces, and by the strongylus in the lungs 
of sheep. 

The researches of Baumgarten have enabled us to follow in detail the 
evolution of a tubercle. 

(a) The multiplication of the tubercle bacilli, which is rapid and is 
accompanied by their dissemination in the surrounding tissues partly by 
growth, partly in the lymph currents. 

(f3) The multiplication of the fixed cells, especially those of connective 
tissue and the endothelium of the capillaries, and the gradual production 
from them of rounded, cuboidal, or polygonal bodies with vesicular nuclei 
— the epithelioid cells — inside some of which the bacilli are soon seen. 

(y) From the vessels of the infected focus, leucocytes, chiefly poly- 



TUBERCULOSIS. 



271 



nuclear, migrate in numbers and accumulate about the focus of infection. 
They do not subdivide. Many undergo rapid destruction. Later, -as the 
little tubercle grows, the leucocytes are chiefly of the mononuclear variety 
(lymphocytes), which do not undergo the rapid degeneration of the poly- 
nuclear forms. 

(8) A reticulum of fibres is formed by the fibrillation and rarefaction 
of the connective-tissue matrix. This is most apparent, as a rule, at the 
margin of the growth. 

(e) In some, but not all, tubercles giant cells are formed by an increase 
in the protoplasm and in the nuclei of an individual cell, or possibly by 
the fusion of several cells. The giant cells seem to be in inverse ratio to 
the number and virulence of the bacilli. In lupus, joint tuberculosis, 
and scrofulous glands, in which the bacilli are scanty, the giant cells are 
numerous; while in miliary tubercles and all lesions in which the bacilli 
are abundant the giant cells are few in number. 

The bacilli then cause, in the first place, a proliferation of the fixed 
elements, with the production of epithelioid and giant cells; and, secondly, 
an inflammatory reaction, associated with exudation of leucocytes. How 
far the leucocytes attack and destroy the bacilli has not been definitely 
settled — Metschnikoff claiming, Baumgarten denying, an active phago- 
cytosis. 

(3) The Degeneration of Tubercle. — There are two chief forms of de- 
generation: 

(a) Caseation. — At the central part of the growth, owing to the direct 
action of the bacilli or their products, a process of coagulation necrosis 
goes on in the cells, which lose their outline, become irregular, no longer 
take stains, and are finally converted into a homogeneous, structureless 
substance. Proceeding from the centre outward, the tubercle may be grad- 
ually converted into a yellowish-gray body, in which, however, the bacilli 
are still abundant. No blood-vessels are found in them. Aggregated to- 
gether these form the cheesy masses so common in tuberculosis, which 
may undergo softening, fibroid limitation (encapsulation), or calcification. 

(b) Sclerosis. — With the necrosis of the cell elements at the centre of the 
tubercle, hyaline transformation proceeds, together with great increase in 
the fibroid elements; so that the tubercle is converted into a firm, hard 
structure. Often the change is rather of a fibro-caseous nature; but the 
sclerosis predominates. In some situations, as in the peritoneum, this 
seems to be the natural transformation of tubercle, and it is by no means 
rare in the lungs. 

In all tubercles two processes go on: the one — caseation — destructive 
and dangerous; and the other — sclerosis — conservative and healing. The 
ultimate result in a given case depends upon the capabilities of the body 
to restrict and limit the growth of the bacilli. There are tissue-soils in 
which the bacilli are, in all probability, killed at once — the seed has fallen 
by the wayside. There are others in which a lodgment is gained and more 
or less damage done, but finally the day is witli the conservative, protecting 
forces — the seed has fallen upon stony ground. Thirdly, there are tissue- 
soils in which the bacilli grow luxuriantly, caseation and softening, not 



272 



SPECIFIC INFECTIOUS DISEASES. 



limitation and sclerosis, prevail, and the day is with the invaders — the seed 
has fallen upon good ground. 

The action of the bacilli injected directly into the blood-vessels illus- 
trates many points in the histology and pathology of tuberculosis. If into 
the vein of a rabbit a pure culture of the bacilli is injected, the microbes 
accumulate chiefly in the liver and spleen. The animal dies usually with- 
in two weeks, and the organs apparently show no trace of tubercles. Micro- 
scopically, in both spleen and liver the young tubercles in process of forma- 
tion are very numerous, and karyokinesis is going on in the liver-cells. 
After an injection of a more dilute culture, or one whose virulence has 
been mitigated by age, instead of dying within a fortnight the animal sur- 
vives for five or six weeks, by which time the tubercles are apparent in the 
spleen and liver, and often in the other organs. 

(4) The diffused Inflammatory Tubercle. — This is most frequently seen in 
the lungs. Only a great master like Yirchow could have won the profes- 
sion from a belief in the unity of phthisis, which the genius of Laennec 
had, on anatomical ground, announced. Here and there a teacher, as 
Wilson Fox. protested, but the heresy prevailed, and we repeated the strik- 
ing aphorism of Xiemeyer, " The greatest evil which can happen to a con- 
sumptive is that he should become tuberculous." It was thought that the 
products of any simple inflammation might become caseous, and that ordi- 
nary catarrhal pneumonia terminated in phthisis. It was peculiarly fitting 
that from Germany, in which the dualistic heresy arose, the truth of Laen- 
nec's views should receive incontestable proof, in the demonstration by 
Koch of the etiological unity of all the various processes known as tuber- 
culous and scrofulous. 

Infiltrated tubercle results from the fusion of many small foci of in- 
fection — so small indeed that they may not be visible to the naked eye, but 
which histologically are seen to be composed of scattered centres, sur- 
rounded by areas in which the air-cells are filled with the products of exu- 
dation and of the proliferation of the alveolar epithelium. Under the influ- 
ence of the bacilli, caseation takes place, usually in small groups of lobules, 
occasionally in an entire lobe, or even the greater part of a lung. In the 
early stage of the process, the tissue has a gray gelatinous appearance, the 
gray infiltration of Laennec. The alveoli contain a sero-fibrinous fluid with 
cells, and the septa are also infiltrated. These cells accumulate and undergo 
coagulation necrosis, forming areas of caseation, the infiltration tuberculeuse 
laune of Laennec. the scrofulous or cheesy pneumonia of later writers. 
There mav also be a diffuse infiltration and caseation without any special 
foci, a widespread tuberculous pneumonia induced by the bacilli. 

After all. the two processes are identical. As Baumgarten states: 
" There is no well-marked difference between miliary tubercle and chronic 
caseous pneumonia. Speaking histologically, miliary tuberculosis is noth- 
ing else than a chronic caseous miliary pneumonia, and chronic caseous 
pneumonia is nothing but a tuberculosis of the lungs.' 5 

(5) Secondary Inflammatory Processes. — (a) The irritation caused by 
the bacilli invariably produces an inflammation which may, as has been 
described, be limited to exudation of leucocytes and serum, but may also be 



TUBERCULOSIS. 



273 



much more extensive, and which varies with varying conditions. We find, 
for example, about the smaller tubercles in the lungs, pneumonia — either 
catarrhal or fibrinous, proliferation of the connective-tissue elements in the 
septa (which also become infiltrated with round cells), and changes in the 
blood and lymph-vessels. 

(b) In processes of minor intensity the inflammation is of the slow 
reactive nature, which results in the production of a cicatricial connective 
tissue which limits and restricts the development of the tubercles and is 
the essential conservative element in the disease. It is to be remembered 
that in chronic pulmonary tuberculosis much of the fibroid tissue which is 
present is not in any way associated with the action of the bacilli. 

(c) Suppuration. Do the bacilli themselves induce suppuration? In 
so-called cold tuberculous abscess the material is not histologically pus, 
but a debris consisting of broken-down cells and cheesy material. It is 
moreover sterile — that is, does not contain the usual pus organisms. The 
products of the tubercle bacilli are probably able to induce suppuration, 
as in joint and bone tuberculosis pus is frequently produced, although this 
may be due to a mixed infection. Koch, it will be remembered, states 
that the " tuberculin " is one of the best agents for the production of ex- 
perimental suppuration. In tuberculosis of the lungs the suppuration is 
largely the result of an infection with pus organisms. 

II. Acute Miliary Tuberculosis. 

The modern knowledge of this remarkable form dates from the state- 
ment of Buhl (1856), that miliary tuberculosis is a specific infection de- 
pendent on the presence in the body of an unencapsulated yellow tubercle, 
or a tuberculous cavity in the lung; and that it bears the same relation to 
the primary lesion as pyaemia does to a focus of suppuration. 

Carl Weigert established the truth of this brilliant conception by dem- 
onstrating the association of miliary tuberculosis with tuberculosis of the 
blood vessels. There are two groups of vessel tubercle — the tuberculous 
periangitis in which there is invasion of the adventitia, and the endangitis 
in which the tubercles start in the intima. The parts most frequently 
affected are the pulmonary veins and the thoracic duct, less often the jugu- 
lar vein, the suprarenal and the vena cava superior, and the sinuses of the 
dura mater, the aorta, and the endocardium. To the branches of the pul- 
monary veins it is not uncommon to find caseous glands adherent, penetrat- 
ing the walls and showing a growth of miliary tubercles in the intima. A 
special interest belongs to tuberculosis of the thoracic duct, first accurately 
described and thoroughly studied by Sir Astley Cooper. Benda in a series 
of 19 cases of vessel tuberculosis found in many instances an enormous num- 
ber of bacilli, particularly in the caseous tubercles of the thoracic duct. 

Access of the bacilli to the blood may take place by the perforation of 
an extra-vascular caseous mass into the lumen, or by iho softening and 
ulceration of a focus of tuberculous endangitis. The bacilli do not increase 
in the blood, but settle in the different organs, producing a generalized 
tuberculosis, of which Weigert recognizes three types or grades: 1. The 



274 



SPECIFIC INFECTIOUS DISEASES. 



acute general miliary tuberculosis, in which the various organs of the body 
are stuffed with miliary and submiliary nodules. II. A second form 
characterized by a small number of tubercles in one or many organs. 
III. The occurrence of numerous tuberculous foci widely spread through- 
out the body, but in a more chronic form; the tubercles are larger and 
many are caseous. It is the chronic generalized tuberculosis of children. 
Transitional forms between these groups occur. In the first variety, which 
we are here considering, there is an eruption into the circulation of an 
enormous number of bacilli. Benda suggests in explanation of the pro- 
found toxaemia seen in certain cases (the typhoid form) that in addition 
the blood is surcharged with toxines from a large caseous focus which has 
eroded the vessel. 

Clinical Forms. — The cases may be grouped into those with the 
symptoms of an acute general infection — the typhoid form; cases in which 
pulmonary symptoms predominate; and cases in which the cerebral or cere- 
brospinal symptoms are marked — tuberculous meningitis. 

Other forms have been recognized, but this division covers a large ma- 
jority of the cases. 

Taking any series of cases it will be found that the meningeal form of 
acute tuberculosis exceeds in numbers the cases with general or marked 
pulmonary symptoms. 

1. General or Typhoid Form. — Symptoms. — The patient here presents 
the symptoms of a profound infection with few if any local signs. The 
cases simulate and are frequently mistaken for typhoid fever. After a 
period of failing health, with loss of appetite, the patient becomes fever- 
ish and weak. Occasionally the disease sets in more abruptly, but in many 
instances the anamnesis closely resembles that of typhoid fever. Nose- 
bleeding, however, is rare. The temperature increases, the pulse becomes 
rapid and feeble, the tongue dry; delirium becomes marked and the cheeks 
are flushed. The pulmonary symptoms may be very slight; usually bron- 
chitis exists, but is not more severe than is common with typhoid fever. 
The pulse is seldom dicrotic, but is rapid in proportion to the pyrexia. Per- 
haps the most striking feature of the temperature is the irregularity; and 
if seen from the outset there is not the steady ascent noted in typhoid fever. 
There is usually an evening rise to 103°, sometimes 104°, and a morning 
remission of from two to three degrees. Sometimes the pyrexia is intermit- 
tent, and the thermometer may register below normal during the early 
morning hours. The inverse type of temperature, in which the rise takes 
place in the morning, is held by some writers to be more frequent in gen- 
eral tuberculosis than in other diseases. In rare instances there may be 
little or no fever. On two occasions I have had a patient admitted to my 
wards in a condition of profound debility, with a history of illness of from 
three to four weeks' duration, with rapid pulse, flushed cheeks, dry tongue, 
and very slight elevation in temperature, in whom (post mortem) the con- 
dition proved to be general tuberculosis. In one instance there was tol- 
erably extensive disease at the right apex. ' Eeinhold, from Baumler's 
clinic, has recently called attention to these afebrile forms of acute tuber- 
culosis. In 9 of 52 cases there was no fever, or only a transient rise. 

In a considerable number of these cases the respirations are increased 



TUBERCULOSIS. 



275 



in frequency, particularly in the early stage, and there may be signs of dif- 
fuse bronchitis and slight cyanosis. Cheyne-Stokes breathing develops 
toward the close. 

Active delirium is rare. More commonly there are torpor and dulness, 
gradually deepening into coma, in which the patient dies. In some cases 
the pulmonary symptoms become more marked; in others, meningeal or 
' cerebral features develop. 

Diagnosis. — The differential diagnosis between general miliary tuber- 
culosis without local manifestations and typhoid fever is extremely diffi- 
cult. A point of importance, to which reference has already been made, 
is the irregularity of the temperature curve. The greater frequency of 
the respirations and the tendency to slight cyanosis is much more com- 
mon in tuberculosis. There are cases, however, of typhoid fever in which 
the initial bronchitis is severe and may lead to dyspnoea and disturbed 
oxygenation. The cough may be slight or absent. Diarrhoea is rare in 
tuberculosis; the bowels are usually constipated; but diarrhoea may occur 
and persist for days. In certain cases the diagnosis has been complicated 
still further by the occurrence of blood in the stools. Enlargement of the 
spleen occurs in general tuberculosis, but is neither so early nor so marked 
as in typhoid fever. In children, however, the enlargement may be con- 
siderable. The urine may show traces of albumin, and unfortunately 
Ehrlich's diazo-reaction, which is so constant in typhoid fever, is also met 
with in general tuberculosis. The absence of the characteristic roseola is 
an important feature. Occasionally in acute tuberculosis reddish spots 
may develop and for a time cause difficulty, but they do not come out in 
crops, and rarely have the characters of the true typhoid eruption. Herpes 
is perhaps more common in tuberculosis. Toward the close, petechia? may 
appear on the skin, particularly about the wrists. A rare event is jaundice, 
due possibly to the eruption of tubercles in the liver. It is to be remem- 
bered that the lesions of acute tuberculosis and of typhoid fever have been 
demonstrated in the same body. 

A negative Widal test and the absence of typhoid bacilli in blood- 
cultures may be of decisive importance in these doubtful cases. In very rare 
instances tubercle bacilli have been found in the blood. Leucocytosis is 
more common in miliary tuberculosis than in typhoid fever in which leu- 
copenia is the rule. Careful examination of the eyes may show choroidal 
tubercles, though I have never known a diagnosis made on their presence 
alone. In the fluid obtained by lumbar puncture the tubercle bacilli may 
be abundant and, as in a recent case, clinch at once the diagnosis. 

2. Pulmonary Form.— Symptoms. — From the outset the pulmonary 
symptoms are marked. The patient may have had a cough for months or 
for years without much impairment of health, or he may be known to be 
the subject of chronic pulmonary tuberculosis. In other instances, particu- 
larly in children, the affection follows measles or whooping-cough, and 
is of a distinctly broncho-pneumonic type. The disease begins with the 
symptoms of diffuse bronchitis. The cough is marked, the expectoration 
muco-purulent, occasionally rusty. Haemoptysis has been noted in a few- 
instances. From the outset dyspnoea is a striking feature and may be out 



276 



SPECIFIC INFECTIOUS DISEASES. 



of proportion to the intensity of the physical signs. There is more or less 
cyanosis of the lips and finger-tips, and the cheeks are suffused. Apart 
from emphysema and the later stages of severe pneumonia I know of no 
other pulmonary condition in which the cyanosis is so marked. The phys- 
ical signs are those of bronchitis. In children there may be defective reso- 
nance at the bases, from scattered areas of broncho-pneumonia; or, what is 
equally suggestive, areas of hyper-resonance. Indeed, the percussion note, 
particularly in the front of the chest, in some cases of miliary tuberculosis, 
is full and clear, and it will be noted (post mortem) that the lungs are 
unusually voluminous. This is probably the result of more or less wide- 
spread acute emphysema. On auscultation, the rales are either sibilant 
and sonorous or small, fine, and crepitant. There may be fine crepitation 
from the occurrence of tubercles on the pleura (Jiirgensen). In children 
there may be high-pitched tubular breathing at the bases or toward the 
root of the lung. Toward the close the rales may be larger and more mu- 
cous. The temperature rises to 102° or 103°, and may present the inverse 
type. The pulse is rapid and feeble. In the very acute cases the spleen 
is always enlarged. The disease may prove fatal in ten or twelve days, or 
may be protracted for weeks or even months. 

Diagnosis. — The diagnosis of this form offers less difficulty and is more 
frequently made. There is often a history of previous cough, or the patient 
is known to be the subject of local disease of the lung, or of the lymph- 
glands, or of the bones. In children these symptoms following measles 
or whooping-cough indicate in the majority of cases acute miliary tuber- 
culosis, with or without broncho-pneumonia. Occasionally the sputum con- 
tains tubercle bacilli. 

The choroidal tubercle occurs in a limited number of cases and may 
help the diagnosis. More important in an adult is the combination of 
dyspnoea with cyanosis and the signs of a diffuse bronchitis. In some in- 
stances the occurrence of cerebral symptoms at once gives a clew to the 
nature of the trouble. 

3. Meningeal Form {Tuberculous Meningitis. Basilar Meningitis). — This 
affection, which is also known as acute hydrocephalus or "water on the 
brain/' is essentially an acute tuberculosis in which the membranes of the 
brain, sometimes of the cord, bear the brunt of the attack. Our first ac- 
curate knowledge of this affection dates from the publication of Eobert 
Whytt's Observations on the Dropsy of the Brain, Edinburgh, 1768. The 
literature is very fully given in the last edition of Barthez and Sannee. 

Though Guersant had as early as 1827 used the name granular menin- 
gitis for this form of inflammation of the meninges, it was not until 1830 
that Papavoine demonstrated the nature of the granules and noted their 
occurrence with tubercles in other parts. 

In 1832 and 1833, W. W. Gerhard, of Philadelphia, made a very careful 
study of the disease in the Children's Hospital at Paris, and his publica- 
tions, more than those of any other author, served to place the disease on 
a firm anatomical and clinical basis. 

There are several special etiological factors in connection with this form. 
It is much more common in children than in adults. It is rare during the 



TUBERCULOSIS. 



277 



first year of life, more frequent between the second and the fifth years. 
In a majority of the eases a focus of old tuberculous disease will be found, 
commonly in the bronchial or mesenteric glands. In a few instances the 
affection seems to be primary in the meninges. It is very difficult, how- 
ever, in an ordinary post mortem to make an exhaustive search, and the 
lesion may be in the bones, sometimes in the middle ear, or in the genito- 
urinary organs. In those instances in which no primary focus has been 
discovered it has been suggested that the bacilli reach the meninges through 
the cribriform plate of the ethmoid from the upper part of the nostrils, but 
this is not probable. 

Morbid Anatomy. — Tuberculous meningitis presents a very character- 
istic picture. The meninges at the base are most involved, hence the term 
basilar meningitis. The parts about the optic chiasm, the Sylvian fissures, 
and the interpeduncular space are affected. There may be only slight tur- 
bidity and matting of the membranes, and a certain stickiness with serous 
infiltration; but more commonly there is a turbid exudate, fibrino-purulent 
m character, which covers the structures at the base, surrounds the nerves, 
extends out into the Sylvian fissures, and appears on the lateral, rarely on 
the upper, surfaces of the hemispheres. The tubercles may be very appar- 
ent, particularly in the Sylvian fissures, appearing as small, whitish nodules 
on the membranes. They vary much in number and size, and may be 
difficult to find. The amount of exudate bears no definite relation to the 
abundance of tubercles. The arteries of the anterior and posterior per- 
forated spaces should be carefully withdrawn and searched, as upon them 
nodular tubercles may be found when not present elsewhere. In doubtful 
cases the middle cerebral arteries should be very carefully removed, spread 
on a glass plate with a black background, and examined with a low ob- 
jective. The tubercles are then seen as nodular enlargements on the smaller 
arteries. The lateral ventricles are dilated (acute hydrocephalus) and con- 
tain a turbid fluid; the ependyma may be softened, and the septum luciclum 
and fornix are usually broken down. The convolutions are often flattened 
and the sulci obliterated owing to the increased intra- ventricular pressure. 
There is a tuberculous endarteritis with the formation of intimal tuber- 
cles, due to implantation of bacilli from the blood (Hektoen). Prolifera- 
tion in the adventitia, with invasion of the media and intima are common, 
forming nodular circumscribed tubercles. The lumen of the vessel is nar- 
rowed and thrombosis may result. The meninges are not alone involved, 
but the contiguous cerebral substance is more or less cedematous and infil- 
trated with leucocytes, so that anatomically the condition is in reality a 
meningo-enceplialitis. 

There are instances in which the acute process is associated with chronic 
meningeal tuberculosis; cases which may for months present the clinical 
picture of brain tumor. 

Although in a majority of instances the process is cerebral, the spinal 
meninges may also be involved, particularly those of the cervical cord. 
There arc cases indeed in which the symptoms are chiefly spinal. A sailor, 
who had fallen on the deck three weeks before his death, was admitted to 
the Montreal General Hospital. He presented signs of meningitis, chiefly 



273 SPECIFIC INFECTIOUS DISEASES. . 

spinal, which were naturally attributed to traumatism. The post mortem 
showed absence of tubercles and lymph at the base of the brain, and an 
extensive eruption of miliary tubercles with much turbid lymph over the 
entire spinal meninges. There were small cheesy masses at the apices of 
the lungs. 

Symptoms. — Tuberculous meningitis presents an extremely complex 
clinical picture. It will be best to describe the form found in children. 

Prodromal symptoms are common. The child may haye been in fail- 
ing health for some weeks, or may be convalescent from measles or whoop- 
ing-cough. In many instances there is a history of a fall. The child gets 
thin, is restless, peevish, irritable, loses its appetite, and the disposition 
may completely change. Symptoms pointing to the disease may then set 
in, either quite suddenly with a convulsion, or more commonly with head- 
ache, vomiting, and fever, three essential symptoms of the onset which 
are rarely absent. The pain may be intense and agonizing. The child 
puts its hand to its head and occasionally, when the pain becomes worse, 
gives a short, sudden cry, the so-called hydrocephalic cry. Sometimes the 
child screams continuously until utterly exhausted. I saw in West Phil- 
adelphia a case of basilar meningitis in a girl of thirteen, who for three 
days, when not under the influence of a powerful sedative or of chloro- 
form, screamed at the top of her voice so as to be heard a square or more 
away. The vomiting is without apparent cause, and is independent of tak- 
ing of food. Constipation is usually present. The fever is slight, but 
gradually rises to 102° or 103°. The pulse is at first rapid, subsequently 
irregular and slow. The respirations are rarely altered. During sleep the 
child is restless and disturbed. There may be twitchings of the muscles, 
or sudden startings; or the child may wake up from sleep in great terror. 
In this early stage the pupils are usually contracted. These are the chief 
symptoms of the initial stage, or, as it is termed, the stage of irritation. 

In the second period of the disease these irritative symptoms subside; 
vomiting is no longer marked, the abdomen becomes retracted, boat-shaped 
or carinated. The bowels are obstinately constipated, the child no longer 
complains of headache, but is dull and apathetic, and when roused is more 
or less delirious. The head is often retracted and the child utters an occa- 
sional cry. The pupils are dilated or irregular, and a squint may develop, 
Sighing respiration is common. Convulsions may occur, or rigidity of 
the muscles of one side or of one limb. The temperature is variable, rang- 
ing from 100° to 102.5°. A blotchy erythema is not uncommon on the 
skin. If the finger-nail is drawn across the skin of any region a red line 
comes out quickly, the so-called tache cerebrate, which, however, has no diag- 
nostic significance. 

In the final period, or stage of paralysis, the coma increases and the 
child cannot be roused. Convulsions are not infrequent, and there are 
spasmodic contractions of the muscles of the back and neck. Spasms may 
occur in the limbs of one side. Optic neuritis and paralysis of the ocular 
muscles may be present. The pupils become dilated, the eyelids are only 
partially closed, and the eyeballs are rolled up so that the corner are only 
covered in part by the upper eyelids. Diarrhoea may occur, the pulse 



TUBERCULOSIS. 



279 



becomes rapid, and the child may sink into a typhoid state with dry tongue, 
low delirium, and involuntary passages of urine and faeces. The tempera- 
ture often becomes subnormal, sinking in rare instances to 93° or 94°. In 
some cases there is an ante-mortem elevation of temperature, the fever rising 
to 106°. The entire duration of the disease is from a fortnight to three 
or four weeks. A leucocytosis is not infrequently present throughout the 
disease. 

There are cases of tuberculous meningitis which pursue a more rapid 
course. They set in with great violence, often in persons apparently in 
good health, and may prove fatal within a few days. In these instances, 
more commonly seen in adults, the convex surface of the brain is usually 
involved. There are again instances which are essentially chronic and 
display symptoms of a limited meningitis; sometimes with pronounced 
psychical symptoms, and sometimes with those of cerebral tumor. 

There are certain features which call for special comment. 

The irregularity and slowness of the pulse in the early and middle 
stages of the disease are points upon which all authors agree. Toward the 
close, as the heart's action becomes weaker, the pulsations are more fre- 
quent. The temperature is usually elevated, but there are instances in 
which it does not rise in the whole course of the disease much above 100°. 
It may be extremely irregular, and the oscillations are often as much as 
three or four degrees in the day. Toward the close the temperature may 
sink to 95°, occasionally to 94°, or there may be hyperpyrexia. In a case 
of Baumler's the temperature rose before death to 43.7° C. (110.7° F.). 

The ocular symptoms of the disease are of special importance. In the 
early stages narrowing of the pupils is the rule. Toward the close, with 
increase in the intra-cranial pressure, the pupils dilate and are irregular. 
There may be conjugate deviation of the eyes. Of ocular palsies the third 
nerve is most frequently involved, sometimes with paralysis of the face, 
limbs, and hypoglossal nerve on the opposite side (syndrome of Weber), due 
to a lesion limited to the inferior and internal part of the crus. The 
changes in the eye-grounds are very important. Neuritis is the most com- 
mon. According to Gowers, the disk at first becomes full colored and has 
hazy outlines, and the veins are dilated. Swelling and striation become pro- 
nounced, but the neuritis is rarely intense. Of 26 cases studied by Gar- 
lick, in 6 the condition was of diagnostic value. The tubercles in the 
choroid are rare and much less frequently seen during life than post-mortem 
figures would indicate. Thus Litten found them (post mortem) in 39 out 
of 52 cases. They were present in only 1 of the 26 cases of tuberculous 
meningitis examined by Garlick. Heinzel examined with negative results 
41 cases. 

Among the motor symptoms convulsions are most common, but there 
are other changes which deserve special mention. A tetanic contraction 
of one limb may persist for several days, or a cataleptic condition. Tremor 
and athctoid movements are sometimes seen. The paralyses are either 
hemiplegias or monoplegias. Hemiplegia may result from disturbance in 
the cortical branches of the middle cerebral artery, occasionally from soften- 
ing in the internal capsule, due to involvement of the central brandies. 



280 



SPECIFIC INFECTIOUS DISEASES. 



Of monoplegias, that of the face is perhaps most common, and if on the 
right side it may occur with aphasia. In two of my cases in adults aphasia 
developed. Brachial monoplegia may be associated with it. In the more 
chronic cases the symptoms persist for months, and there may be a char- 
acteristic Jaeksonian epilepsy. Kernig's sign is present as a rule (see 
Cerebro-spmal Fever). 

The diagnosis of tuberculous meningitis is rarely difficult, and points 
upon which special stress is to be laid are the existence of a tuberculous 
focus in the body, .the mode of onset and the symptoms, and the evidence 
obtained on lumbar puncture. The fluid withdrawn is usually turbid, and 
in it, on centrifugalizing, the bacilli may be discovered. A sterile fluid, 
which is sometimes present, also favors the diagnosis of tuberculous menin- 
gitis. 

The prognosis in this form of meningitis is always most serious. I have 
neither seen a case which I regarded as tuberculous recover, nor have I 
seen post-mortem evidence of past disease of this nature. Cases of recovery 
have been reported by reliable authorities, but they are extremely rare, and 
there is always a reasonable doubt as to the correctness of the diagnosis. 
The differential features and treatment will be considered in connection 
with acute meningitis. 

III. Tuberculosis of the Lymphatic System. 
1. Tuberculosis of the Lymph-glands (Scrofula). 

Scrofula is tubercle, as it has been shown that the bacillus of Koch is 
the essential element. Formerly special attention was given to different 
types of scrofula, of which two important forms were recognized — the san- 
guine, in which the child was slightly built, tall, with small limbs, a fine 
clear skin, soft silky hair, and was mentally very bright and intelligent; 
and the phlegmatic type, in which the child was short and thick-set, with 
coarse features, muddy complexion, and a dull, heavy aspect, It is not yet 
definitely settled whether the virus which produces the chronic tuberculous 
adenitis or scrofula differs from that which produces tuberculosis in other 
parts, or wmether it is the local conditions in the glands which account 
for the slow development and milder course. The experiments of Arloing 
would indicate that the virus was attenuated or milder, for he has shown 
that the caseous material of a lymph-gland killed guinea-pigs, while rab- 
bits escaped. The guinea-pig, as is well known, is the more susceptible 
animal of the two. The observations of Lingard are still more conclusive, 
as showing a variation in the virulence of the tubercle bacillus. Guinea- 
pigs inoculated with ordinary tubercle showed lymphatic infection within 
the first week, and the animals died within three months; infected with 
material from scrofulous glands, the lymphatic enlargement did not ap- 
pear until the second or third week, and the animals survived for six or 
seven months. He showed, moreover, that the virulence of the infection ob- 
tained from the scrofulous glands increased in intensity by passing through 
a series of guinea-nigs. Eve's experiments show that scrofulous material 
invariably produces tuberculosis in guinea-pigs and very often in rabbits. 



TUBERCULOSIS. 



281 



Tuberculous adenitis is met with at all ages. It is more common in 
children than in adults, but it is not infrequent in the middle period of 
life, and may occur in old age. 

The tubercle bacillus is ubiquitous. All are exposed to infection, and 
upon the local conditions, whether favorable or unfavorable, depend the 
fate of those organisms which find lodgment in our bodies. It is possible, 
of course, that tuberculous adenitis may be congenital, but such instances 
must be extremely rare. A special predisposing factor in lymphatic tuber- 
culosis is catarrhal inflammation of the mucous membranes, which in itself 
excites slight adenitis of the neighboring glands. In a child with con- 
stantly recurring naso.-pharyngeal catarrh, the bacilli which lodge on the 
mucous membranes find in all probability the gateways less strictly guarded 
and are taken up by the lymphatics and passed to the nearest glands. The 
importance of the tonsils as an infection-atrium has of late been urged. 
In conditions of health the local resistance, or, as some would put it, the 
phagocytes, would be active enough to deal with the invaders, but the irri- 
tation of a chronic catarrh weakens the resistance of the lymph-tissue and 
the bacilli are enabled to develop and gradually to change a simple into 
a tuberculous adenitis. The frequent association of tuberculous adenitis 
of the bronchial glands with whooping-cough and with measles, and the 
frequent development of tubercle in the mesenteric. glands in children with 
intestinal catarrh, find in this way a rational explanation. After all, as 
Yirchow pointed out, an increased vulnerability of the tissue, however 
brought about, is the important factor in the disease. 

The following are some of the features of interest in tuberculous ade- 
nitis: 

(a) The local character of the disease. Thus, the glands of the neck, or 
at the bifurcation of the bronchi, or those of the mesentery, may be alone 
involved. 

(b) The tendency to spontaneous healing. In a large proportion of 
the cases the battle which ensues between the bacilli and the tissue-cells is 
long; but the latter are finally successful, and we find in the calcified 
remnants in the bronchial and mesenteric lymph-glands evidences of vic- 
tory. Too often in the bronchial glands a truce only is declared and hos- 
tilities may break out afresh in the form of an acute tuberculosis. 

(c) The tendency of tuberculous adenitis to pass on to suppuration. 
The frequency with which, particularly in the glands of the neck, we find 
the tuberculous processes associated with pus is a special feature of this 
form of adenitis. In nearly all instances the pus is sterile. Whether the 
suppuration is excited by the bacilli or by their products, or whether it is 
the result of a mixed infection with pus organisms, which are subsequently 
destroyed, has not been settled. 

(d) The existence of an unhealed focus of tuberculous adenitis is a 
constant menace to the organism. It is safe to say that in three fourths of 
the instances of acute tuberculosis the infection is derived Prom this source. 
On the other hand, it has been urged that scrofula in childhood <rivos a sort 
of protection against tuberculosis in adult life. We certainly do meet with 
many persons of exceptional bodily vigor who in childhood had enlarged 



282 



SPECIFIC INFECTIOUS DISEASES. 



glands, but the evidence which Marfan brings forward in support of this 
view is not conclusive. 

Clinical Forms. — 1. Generalized Tuberculous Lymphadenitis. — In 

exceptional instances we find diffuse tuberculosis of nearly all the lymph- 
glands of the body with little or no involvement of other parts. The most 
extreme cases of it, which I have seen, have been in negro patients. Two 
well-marked cases occurred at the Philadelphia Hospital. In a woman, 
the chart from April, 1888, until March, 1889, showed persistent fever, 
ranging from 101° to 103°, occasionally rising to lOi 0 . On December 16th 
the glands on the right side of the neck were removed. After an attack 
of erysipelas, on February 17th, she gradually sank and died March 5th. 
The lungs presented only one or two puckered spots at the apices. The 
bronchial, retro-peritoneal, and mesenteric glands were greatly enlarged 
and caseous. There was no intestinal, uterine, or bone disease. The con- 
tinuous high fever in this case depended apparently upon the tuberculous 
adenitis, which was much more extensive than was supposed during life. 
In these instances the enlargement is most marked in the retro-peritoneal, 
bronchial, and mesenteric glands, but may be also present in the groups of 
external glands. Occurring acutely, it presents a picture resembling Hodg- 
kin's disease. In a case which died in the Montreal General Hospital this 
diagnosis was made. The cervical and axillary glands were enormously en- 
larged, and death was caused by infiltration of the larynx. In infants and 
children there is a form of general tuberculous adenitis in which the vari- 
ous groups of glands are successively, more rarely simultaneously, involved, 
and in which death is caused either by cachexia, or by an acute infection 
of the meninges. 

2. Local Tuberculous Adenitis. — (a) Cervical. — This is the most com- 
mon form met with in children. It is seen particularly among the poor 
and those who live continuously in the impure atmosphere of badly venti- 
lated lodgings. Children in foundling hospitals and asylums are specially 
prone to the disease. In this country it is most common in the negro race. 
As already stated, it is often met with in catarrh of the nose and throat, or 
chronic enlargement of the tonsils; or the child may have had eczema 
of the scalp or a purulent otitis. 

The submaxillary glands are first involved, and are popularly spoken 
of as. enlarged kernels. They are usually larger on one side than on the 
other. As they increase in size, the individual tumors can be felt; the 
surface is smooth and the consistence firm. They may remain isolated, but 
more commonly they form large, knotted masses, over which the skin is, 
as a rule, freely movable. In many cases the skin ultimately becomes 
adherent, and inflammation and suppuration occur. An abscess points and, 
unless opened, bursts, leaving a sinus which heals slowly. The disease 
is frequently associated with coryza, with eczema of the scalp, ear, or lips, 
and with conjunctivitis or keratitis. When the glands are large and grow- 
ing actively, there is fever. The subjects are usually ansemic, particularly 
if suppuration has occurred. The progress of this form of adenitis is slow 
and tedious. Death, however, rarely follows, and many aggravated cases 
in children ultimately get well. Not only the submaxillary group, but the 



TUBERCULOSIS. 



283 



glands above the clavicle and in the posterior cervical triangle, may be 
involved. In other instances the cervical and axillary glands are involved 
together, forming a continuous chain which extends beneath the clavicle 
and the pectoral muscle. With them the bronchial glands may also be 
enlarged and caseous. Not infrequently the enlargement of the supra- 
clavicular and axillary group of glands on one side precedes the develop- 
ment of a tuberculous pleurisy or of pulmonary tuberculosis. 

(b) Tracheo-bronchial. — The mediastinal lymph-glands constitute niters 
in which lodge the various foreign particles which escape the normal 
phagocytes of bronchi and lungs. Among these foreign particles, and prob- 
ably attached to them, tubercle bacilli are not uncommon, and we find 
tubercles and caseous matter with great frequency in the mediastinal 
glands, particularly those about the bronchi. It is stated that this process 
is always secondary to a focus, however small, in the lungs, but my experi- 
ence does not bear out such a statement. As already mentioned, North- 
rup found them involved in every one of 127 cases at the New York Found- 
ling Hcspital. This tuberculous adenitis may, in the bronchial glands, 
attain the dimensions of a tumor of large size. But even when this occurs 
there may be no pressure symptoms. In children the bronchial adenitis 
is apt to be associated with suppuration. The effects of these enlarged 
glands are very varied, and for full details the reader is referred to the 
elaborate section in the Traite of Barthez and Sannee (tome iii). It is suf- 
ficient here to say that there are instances on record of compression of the 
superior cava, of the pulmonary artery, and of the azygos vein. The trachea 
and bronchi, though often flattened, are rarely seriously compressed. The 
pneumogastric nerve may be involved, particularly the recurrent laryngeal 
branch. More important really are the perforations of the enlarged and 
softened glands into the bronchi or trachea, or a sort of secondary cyst 
may be formed between the lung and the trachea. Asphyxia has been 
caused by blocking of the larynx by a caseous gland which has ulcerated 
through the bronchus (Voelcker), and Cyril Ogle has reported a case in 
which the ulcerated gland practically occluded both bronchi. Perfora- 
tions of the vessels are much less common, but the pulmonary artery and 
the aorta have been opened. Perforation of the oesophagus has been de- 
scribed in several c?ses. One of the most serious effects is infection of the 
lung or pleura by the caseous glands situated deep along the bronchi. This 
may, as is often clearly seen, be by direct contact, and it may be difficult 
to determine in some sections where the caseous bronchial gland terminates 
and the pulmonary tissue begins. In other instances it takes place along 
the root of the lung and is subpleural. Among other sequences may be 
mentioned diverticulum of the oesophagus following adhesion of an enlarged 
gland and its subsequent retraction; and, in the case of the anterior medi- 
astinal and aortic groups, the frequent production of pericarditis, either 
by contact or by rupture of a softened gland into the sac. 

A serious danger is systemic infection, which takes place through ihe 
vessels. 

(c) Mesenteric ; Tabes mesenterica. — In this affection, the abdominal 
scrofula of old writers, the glands of the mesentery and retro-peritonauun 

18 



284 



SPECIFIC INFECTIOUS DISEASES. 



become enlarged and caseate; more rarely they suppurate or calcify. A 
slight tuberculous adenitis is extremely common in children, and is often 
accidentally found (post mortem) when the children have died of other 
diseases. It may be a primary lesion associated with intestinal catarrh, or 
it may be secondary to tuberculous disease of the intestines. 

The primary cases are very common in children, as may be gathered 
from Woodhead's figures, already given. The general involvement of the 
glands interferes seriously with nutrition, and the patients are puny, wasted, 
and anaemic. The abdomen is enlarged and tympanitic; diarrhoea is a con- 
stant feature; the stools are thin and offensive. There is moderate fever, 
but the general wasting and debility are the most characteristic features. 
The enlarged glands cannot often be felt, owing to the distended condi- 
tion of the bowels. These cases are often spoken of as consumption of the 
bowels, but in a majority of them the intestines do not present tuberculous 
lesions. In a considerable number of the cases of tabes mesenterica the 
peritonaeum is also involved, and in such the abdomen is large and hard, 
and nodules may be felt. 

In adults tuberculous disease of the mesenteric glands may occur as a 
primary affection, or in association with pulmonary disease. Galrdner 
gives a remarkable instance of the kind in a man aged twenty-one. In- 
stances of this sort are not uncommon in the literature. Large tumors 
may exist without tuberculous disease in the intestines or in any other 
part. 

The diagnosis of local and general tuberculous adenitis from lymphade- 
noma will be subsequently considered. 
2. Tuberculosis of the Serous Membranes. 

General Serous Membrane Tuberculosis (Potyorrhomenitis). — The se- 
rous membranes may be chiefly involved, simultaneously or consecutively, 
presenting a distinctive and readily recognizable clinical type of tuber- 
culosis. There are three groups of cases. First, those in which an acute 
tuberculosis of the peritonaeum and pleurae develops rapidly, caused by local 
disease of the tubes in women, or of the mediastinal or bronchial tymph- 
glands. Secondly, cases in which the disease is more chronic, with exuda- 
tion into both peritonaeum and pleurae, the formation of cheesy masses, and 
the occurrence of ulcerative and suppurative processes. Thirdly, there are 
cases in which the pleuro-peritoneal affection is still more chronic, the tu- 
bercles hard and fibroid, the membranes much thickened, and with little or 
no exudate. In any one of these three forms the pericardium may be in- 
volved with the pleurae and peritonaeum. It is important to bear in mind 
that there may be in these cases no visceral tuberculosis. . 

Tuberculosis of the Pleura. — 1. Acute tuberculous pleurisy. It is dif- 
ficult in the present state of our knowledge to estimate the proportion of 
instances of acute pleurisy due to tuberculosis (see Acute Pleurisy). The 
cases are rarely fatal. In the study of those in the Johns Hopkins Hos- 
pital, which I made for the Shattuek Lecture (Boston Med. and Surg. 
Journal, 1893), there were three groups of cases: (a) Acute tuberculous 
pleurisy with subsequent chronic course. (b) Secondary and terminal 
forms of acute pleurisy (these are not uncommon in hospital practice). 



TUBERCULOSIS. 



2S5 



And (c) a form of acute tuberculous suppurative pleurisy. A considerable 
number of the purulent pleurisies, designated as latent and chronic, are 
caused by tubercle bacilli, but the fact is not so widely recognized that 
there is an acute, ulcerative, and suppurative disease^which may run a very 
rapid course. The pleurisy sets in abruptly, with pain in the side, fever, 
cough, and sometimes with a chill. There may be nothing to suggest a 
tuberculous process, and the subject may have a fine physique and come 
of healthy stock. 2. The subacute and chronic tuberculous pleurisies are 
more common. The largest group of cases comprises those with sero- 
fibrinous effusion. The onset is insidious, the true character of the disease 
is frequently overlooked, and in almost every instance there are tubercu- 
lous foci in the lungs and in the bronchial glands. These are cases in 
which the termination is often in pulmonary tuberculosis or general 
miliary tuberculosis. In not a few of them the exudate becomes puru- 
lent. 

And, lastly, there is a chronic adhesive pleurisy, a primary proliferative 
form which is of long standing, may lead to very great thickening of the 
membrane, and sometimes to invasion of the lung. For a fuller considera- 
tion the reader is referred to my Shattuck Lecture or to the section on 
tuberculosis in Loomis and Thompson's System of Medicine. 

Secondary tuberculous pleurisy is very common. The visceral layer is 
always involved in pulmonary tuberculosis. Adhesions usually form and 
a chronic pleurisy results, which may be simple, but usually tubercles are 
scattered through the adhesions. An acute tuberculous pleurisy may re- 
sult from direct extension. The fluid may be sero-fibrinous or hamior- 
rhagic, or may become purulent. And, lastly, a very common event in 
pulmonary tuberculosis is the perforation of a superficial spot of softening, 
and the production of pyo-pneumotliorax. 

The general symptomatology of these forms will be considered under 
disease of the pleura. 

Tuberculosis of the Pericardium. — Miliary tubercles may occur as a 
part of a general infection, but the term is properly limited to those cases 
in which, either as a primary or secondary process, there is extensive dis- 
ease of the membrane. Tuberculosis is not so common in the pericardium 
as in the pleura and peritonaeum, but it is certainly more common than 
the literature would lead us to suppose. Seventeen cases had come under 
my observation to January, 1893 (American Journal of the Medical Sci- 
ences). 

We may recognize four groups of cases: First, those in which the con- 
dition is entirely latent, and the disease is discovered accidentally in 
individuals who have died of other affections or of chronic pulmonary 
tuberculosis. 

A second group, in which the symptoms are those of cardiac insuf- 
ficiency following the dilatation and hypertrophy consequent upon a 
chronic adhesive pericarditis. The symptoms are those of cardiac dropsy, 
and suggest either idiopathic hypertrophy and dilatation, or, if there is a 
loud blowing systolic murmur at the apex, mitral valve disease, either in- 
sufficiency or stenosis. There are cases of adherent pericardium in which 



286 



SPECIFIC INFECTIOUS DISEASES. 



a bruit is heard which resembles the rumbling presystolic murmur (Hale 
White). The condition of adherent pericardium is usually overlooked. 

In a third group the clinical picture is that of an acute tuberculosis, 
either general or with cerebro-spinal manifestations, which has had its 
origin from the tuberculous pericardium or tuberculous mediastinal lymph- 
glands. 

A fourth group, with symptoms of acute pericarditis, includes cases in 
which the affection is acute and accompanied with more or less exudation 
of a sero-fibrinous, haemorrhagic, or purulent character. There may be no 
suspicion whatever of the tuberculous nature of the trouble. 

(d) Tuberculosis of the Peritonaeum. — In connection with miliary and 
chronic pulmonary tuberculosis it is not uncommon to find the peritonaeum 
studded with small gray granulations. They are constantly present on 
the serous surface of tuberculous ulcers of the intestines. Apart from 
these conditions the membrane is often the seat of extensive tuberculous 
disease, which occurs in the following forms: 

(1) Acute miliary tuberculosis with sero-fibrinous or bloody exudation. 

(2) Chronic tuberculosis, characterized by larger growths, which tend 
to caseate and ulcerate. It may lead to perforation of the intestinal coils. 
The exudate is purulent or sero-purulent, and is often sacculated. 

(3) Chronic fibroid tuberculosis, which may be subacute from the onset, 
or which may represent the final stage of an acute miliary eruption. The 
tubercles are hard and pigmented. There is little or no exudation, and 
the serous surfaces are matted together by adhesions. 

The process may be primary and local, which was the case in 5 of my 
17 post mortems. In children the infection appears to pass from the intes- 
tines, and in adults this is the source in the cases associated with chronic 
phthisis. In women the disease extends commonly from the Fallopian 
tubes. In at least 30 or 40 per cent of the instances of laparotomy in this 
affection reported by gynaecologists the infection was from them. The 
prostate or the seminal vesicles may be the starting-point. In many cases 
the peritonaeum is involved with the pleura and pericardium, particularly 
with the former membrane. 

It is interesting to note that certain morbid conditions of the abdominal 
organs predispose to the development of the disease; thus patients with 
cirrhosis of the liver very often die' of an acute tuberculous peritonitis. 
The frequency with which the condition is met with in operations upon 
ovarian tumors has been commented upon by gynaecologists. Many cases 
have followed trauma of the abdomen. A very interesting feature is the 
development of tuberculosis in hernial sacs. The condition is not very 
uncommon. In a majority of the instances it has been discovered acci- 
dentally during the operation for radical cure or for strangulation. In 
7 instances the sac alone was involved. 

It is generally stated that males are attacked oftener than females. 
In my own series of 21 cases, 15 were males. The recent laparotomies, 
however, which have been performed in this disease have been chiefly in 
females; so that in the collected statistics I find the cases to be twice as 
numerous in females as in males; in the ratio, indeed, of 131 to 60. 



TUBERCULOSIS. 



287 



Tuberculous peritonitis occurs at all ages. It is common in children 
associated with intestinal and mesenteric disease. The incidence is most 
frequent between the ages of twenty and forty. It may occur in advanced 
life. In one of my cases the patient was eighty-two years of age. Of 
357 cases collected from the literature,* there were under ten years, 27; 
between ten and twenty, 75; from twenty to thirty, 87; between thirty 
and forty, 71; from forty to fifty, 61; from fifty to sixty, 19; from sixty 
to seventy, 4; above seventy, 2. In America it is more common in the 
negro than in the white race. 

Symptoms. — In certain special features the tuberculous varies con- 
siderably from other forms of peritonitis. It presents a symptom-complex 
of extraordinary diversity. 

In the first place, the process may be latent and not cause a single 
symptom. Such are the cases met with accidentally in the operation for 
hernia or for ovarian tumor. In direct contrast are the instances in 
which the onset is so sudden and violent that the diagnosis of enteritis 
or hernia is made. The operation for strangulated hernia has, indeed, 
been performed. Many cases set in acutely with fever, abdominal ten- 
derness, and the symptoms of ordinary acute peritonitis. Cases with 
a slow onset, abdominal tenderness, tympanites, and low continuous 
fever resemble typhoid fever very closely, and may lead to error in diag- 
nosis. 

Ascites is frequent, but the effusion is rarely large. It is sometimes 
hemorrhagic. In this form the diagnosis may rest between an acute miliary 
cancer, cirrhosis of the liver, and a chronic simple peritonitis — conditions 
which usually offer no special difficulties in differentiation. A most impor- 
tant point is the simultaneous presence of a pleurisy. The tuberculin test 
may be used. Tympanites may be present in the very acute cases, when 
it is due to loss of tone in the intestines, owing to inflammatory infiltra- 
tion; or it may occur in the old, long-standing cases when universal adhe- 
sion has taken place between the parietal and visceral layers. Fever is a 
marked symptom in the acute cases, and the temperature may reach 103° 
or 104°. In many instances the fever is slight. In the more chronic eases 
subnormal temperatures are common, and for days the temperature may 
not rise above 97°, and the morning record may be as low as 95.5°. Ani 
occasional symptom is pigmentation of the skin, which in some cases has 
led to the diagnosis of Addison's disease. A striking peculiarity of tuber- 
culous peritonitis is the frequency with which either the condition simu- 
lates or is associated with tumor. These may be: 

(a) Omental, due to puckering and rolling of this membrane until it 
forms an elongated firm mass, attached to the transverse colon and lying 
athwart the upper part of the abdomen. This cord-like structure is found 
also with cancerous peritonitis, but is much more common in tuberculosis. 
Gairdner has called special attention to this form of tumor, and in children 
has seen it undergo gradual resolution. A resonant percussion note may 
sometimes be elicited above the mass. Though usually situated near the 



* Johns Hopkins Hospital Reports, vol. ii. 



288 



SPECIFIC INFECTIOUS DISEASES. 



umbilicus, the omental mass may form a prominent tumor in the right 
iliac region. 

(b) Sacculated exudation, in which the effusion is limited and confined 
by adhesions between the coils, the parietal peritonaeum, the mesentery, 
and the abdominal or pelvic organs. This encysted exudate is most com- 
mon in the middle zone, and has frequently been mistaken for ovarian 
tumor. It may occupy the entire anterior portion of the peritonaeum, or 
there may be a more limited saccular exudate on one side or the other. 
It may lie completely within the pelvis proper, associated with tuberculous 
disease of the Fallopian tubes. 

(c) In rare cases the tumor formations may be due to great retraction 
or thickening of the intestinal coils. The small intestine is found short- 
ened, the walls enormously thickened, and the entire coil may form a firm 
knot close against the spine, giving on examination the idea of a solid 
mass. Not the small intestine only, but the entire bowel from the duode- 
num to the rectum, has been found forming such a hard nodular tumor. 

(d) Mesenteric glands, which occasionally form very large, tumor-like 
masses, more commonly found in children than in adults. This condition 
may be confined to the abdominal glands. Ascites may coexist. The con- 
dition must be distinguished from that in children, in which, with ascites or 
tympanites — sometimes both — there can be felt irregular nodular masses, due 
to large caseous formations between the intestinal coils. No doubt in a con- 
siderable number of cases of the so-called tabes mesenterica, particularly in 
those with enlargement and hardness of the abdomen — the condition which 
the French call carreau — there is involvement also of the peritonaeum. 

The diagnosis of these peritoneal tumors is sometimes very difficult. 
The omental mass is a less frequent source of error than any other; but, 
as already mentioned, a similar condition may occur in cancer. The most 
important problem is the diagnosis of the saccular exudation from ovarian 
tumor. In fully one third of the recorded cases of laparotomy in tuber- 
culous peritonitis, the diagnosis of cystic ovarian disease had been made. 
The most suggestive points for consideration are the history of the patient 
and the evidence of old tuberculous lesions. The physical condition is not 
of much help, as in many instances the patients have been robust and 
well nourished. Irregular febrile attacks, gastro-intestinal disturbance, 
and pains are more common in tuberculous disease. Unless inflamed there 
is usually not much fever with ovarian cysts. The local signs are very 
deceptive, and in certain cases have conformed in every particular to those 
of cystic disease. The outlines in saccular exudation are rarely so well 
defined. The position and form may be variable, owing to alterations in 
the size of the coils of which in parts the walls are composed. Nodular 
cheesy masses may sometimes be felt at the periphery. Depression of the 
vaginal wall is mentioned as occurring in encysted peritonitis; but it is 
also found in ovarian tumor. Lastly, the condition of the Fallopian tubes, 
of the lungs and of the pleurae, should be thoroughly examined. The asso- 
ciation of salpingitis with an ill-defined anomalous mass in the abdomen 
should arouse suspicion, as should also involvement of the pleura, the apex 
of one lung, or a testis in the male. 



TUBERCULOSIS. 



289 



IV. Pulmonary Tuberculosis (Phthisis, Consumption). 

Three clinical groups may be conveniently recognized: (1) tuberculo- 
pneumonic phthisis — acute phthisis; (2) chronic ulcerative phthisis; and (3) 
fibroid phthisis. 

According to the mode of infection there are two distinct types of 
lesions: 

(a) When the bacilli reach the lungs through the blood-vessels or lym- 
phatics the primary lesion is usually in the tissues of the alveolar walls, in 
the capillary vessels, the epithelium of the air-cells, and in the connective- 
tissue framework of the septa. The process of cell division proceeds as 
already described in the general histology of tubercle. The irritation of 
the bacilli produces, within a few days, the small, gray miliary nodules, 
involving several alveoli and consisting largely of round, cuboidal, uni- 
nuclear epithelioid cells. Depending upon the number of bacilli which 
reach the lung in this way, either a localized or a general tuberculosis is 
excited. The tubercles may be uniformly scattered through both lungs 
and form a part of a general miliary tuberculosis, or they may be confined 
to the lungs, or even in great part to one lung. The changes which the 
tubercles undergo have already been referred to. The further stages 
may be: (1) Arrest of the process of cell division, gradual sclerosis of the 
tubercle, and ultimately complete fibroid transformation. (2) Caseation 
of the centre of the tubercle, extension at the periphery by proliferation of 
the epithelioid and lymphoid cells, so that the individual tubercles or 
small groups become confluent and form diffuse areas which undergo case- 
ation and softening. (3) Occasionally as a result of intense infection of a 
localized region through the blood-vessels the tubercles are thickly set. 
The intervening tissue becomes acutely inflamed, the air-cells are filled 
with the products of a desquamative pneumonia, and many lobules are 
involved. 

(b) When the bacilli reach the lung through the bronchi — inhalation 
or aspiration tuberculosis — the picture differs. The smaller bronchi and 
bronchioles are more extensively affected; the process is not confined to 
single groups of alveoli, but has a more lobular arrangement, and the 
tuberculous masses from the outset are larger, more diffuse, and may in 
some cases involve an entire lobe or the greater part of a lung. It is in 
this mode of infection that we see the characteristic peri-bronchial granu- 
lations and the areas of the so-called nodular broncho-pneumonia. These 
broncho-pneumonic areas, with on the one hand caseation, ulceration, and 
cavity formation, and on the other sclerosis and limitation, make up the 
essential elements in the anatomical picture of tuberculous phthisis. 

1. Acute Pneumonic Tuberculosis of the Lungs. 

This form, known also by the name of galloping consumption, is met 
with both in children and adults. In the former many of the cases are 
mistaken for simple broncho-pneumonia. 

Two types may be recognized, the pneumonic and broncho-pneumonic. 



290 



SPECIFIC INFECTIOUS DISEASES. 



(a) In the pneumonic form one lobe may be involved, or in some in- 
stances an entire lung. The organ is heavy, the affected portion airless; 
the pleura is usually covered with a thin exudate, and on section the picture 
resembles closely that of ordinary hepatization. The following is an extract 
from the post-mortem report of a case in which death occurred twenty-nine 
days after the onset of the illness, having all the characters of an acute 
pneumonia: " Lef t lung weighs 1,500 grammes (double the weight of the 
other organ) and is heavy and airless, crepitant only at the anterior mar- 
gins. Section shows a small cavity the size of a walnut at the apex, about 
which are scattered tubercles in a consolidated tissue. The greater part 
of the lung presents a grayish-white appearance due to the aggregation 
of tubercles which in some places have a continuous, uniform appearance, 
in others are surrounded by an injected and consolidated lung-tissue. 
Toward the margins of the lower lobe strands of this firm reddish tissue 
separate anaemic, dry areas. There are in the right lung three or four 
small groups of tubercles but no caseous masses. The bronchial glands 
are not tuberculous." Here the intense local infection was due to the 
small focus at the apex of the lung, probably an aspiration process. 

Only the most careful inspection may reveal the presence of miliary 
tubercles, or the attention may be arrested by the detection of tubercles in 
the other lung or in the bronchial glands. The process may involve only 
one lobe. There may be older areas which are of a peculiarly yellowish- 
white color and distinctly caseous. The most remarkable picture is pre- 
sented by cases of this kind in which the disease lasts for some months. 
A lobe or an entire lung may be enlarged, firm, airless throughout, and 
converted into a dry, yellowish-white, cheesy substance. Cases are met 
with in which the entire lung from apex to base is in this condition, with 
perhaps only a small, narrow area of air-containing tissue on the margin. 
More commonly, if the case has lasted for two or three months, rapid 
softening has taken place at the apex with extensive cavity formation. 

In a recent study A. Fraenkel and Troje found tubercle bacilli alone 
in 11 of 12 cases. They suggest that in these cases of infection by aspira- 
tion the large areas of exudative inflammation, at some distance even from 
the seat of growth of the bacilli, are due to the presence of some diffusible 
poison produced by the germs. 

Symptoms. — The attack sets in abruptly with a chill, usually in an 
individual who has enjoyed good health, although in many cases the onset 
has been preceded by exposure to cold, or there have been debilitating cir- 
cumstances. The temperature rises rapidly after the chill, there are pain 
in the side, and cough, with at first mucoid, subsequently rusty-colored 
expectoration which may contain tubercle bacilli. The dyspnoea may be- 
come extreme and the patient may have suffocative attacks. The physical 
examination shows involvement of one lobe or of one lung, with signs of 
consolidation, dulness, increased fremitus, at first feeble or suppressed 
vesicular murmur, and subsequently well-marked bronchial breathing. The 
upper or lower lobe may be involved, or in some cases the entire lung. 

At this time, as a rule, no suspicion enters the mind of the practitioner 
that the case is anything but one of frank lobar pneumonia. Occasionally 



TUBERCULOSIS. 



291 



there ma)' be suspicious circumstances in the history of the patient 
or in his family; but, as a rule, no stress is laid upon them in view of 
the intense and characteristic mode of onset. Between the eighth and 
tenth day, instead of the expected crisis, the condition becomes aggravated, 
the temperature is irregular, and the pulse more rapid. There may be 
sweating, and the expectoration becomes muco-purulent and greenish in 
color — a point of special importance, to which Traube called attention. 
Even in the second or third week, with the persistence of these symptoms, 
the physician tries to console himself with the idea that the case is one of 
unresolved pneumonia, and that all will yet be well. Gradually, however, 
the severity of the symptoms, the presence of physical signs indicating 
softening, the existence of elastic tissue and tubercle bacilli in the sputa 
present the mournful proofs that the case is one of acute pneumonic 
phthisis. Death may occur before softening takes place, even in the second 
or third week. In other cases there is extensive destruction at the apex, 
with rapid formation of cavity, and the case may drag on for two or three 
months or may become one of chronic phthisis. 

Diagnosis. — It is by no means widely recognized in the profession 
that there is a form of acute phthisis which may closely simulate ordinary 
pneumonia. Waters, of Liverpool, gave an admirable description of these 
cases, and called attention to the difficulty in distinguishing them from 
ordinary pneumonia. Certainly the mode of onset affords no criterion 
whatever. A healthy, robust-looking young Irishman, a cab-driver, who 
had been kept waiting on a cold, blustering night until three in the morn- 
ing, was seized the next afternoon with a violent chill, and the following 
day was admitted to my wards at the University Hospital, Philadelphia. 
He was made the subject of a clinical lecture on the fifth day, when there 
was absent no single feature in history, symptoms, or physical signs of 
acute lobar pneumonia of the right upper lobe. It was not until ten days 
later, when bacilli were found in his expectoration, that we were made 
aware of the true nature of the case. I know of no criterion by which 
cases of this kind can be distinguished in the early stage. The tubercle 
bacilli may not be present at first, but in one of Fraenkel and Troje's cases 
they existed alone in the typical pneumonic sputum. A point to which 
Traube called attention, and which is also referred to as important by 
Herard and Cornil, is the absence of breath-sounds in the consolidated 
region; but this, I am sure, does not hold good in all cases. The tubular 
breathing may be intense and marked as early as the fourth day; and 
again, how common it is to have, as one of the earliest and most suggestive 
symptoms of lobar pneumonia, suppression or enfeeblement of the vesicular 
murmur! In many cases, however, there are suspicious circumstances in 
the onset: the patient has been in bad health, or may have had previous 
pulmonary trouble, or there are recurring chills. Careful examination 
of the sputa and a study of the physical signs from day to day can alone 
determine the true nature of the case. A point of some moment is the 
character of the fever, which in true pneumonia is more continuous, par- 
ticularly in severe cases, whereas in this form of tuberculosis remissions of 
1.5° or 2° are not infrequent. 



292 



SPECIFIC INFECTIOUS DISEASES. 



(b) Acute tuberculous broncho-pneumonia is more common, particularly 
in children, and forms a majority of the cases of phthisis florida, or " gal- 
loping consumption." It is an acute caseous broncho-pneumonia, starting 
in the smaller tubes, which become blocked with a cheesy substance, while 
the air-cells of the lobule are filled with the products of a catarrhal pneu- 
monia. In the early stages the areas have a grayish-red, later an opaque- 
white, caseous appearance. By the fusion of contiguous masses an entire 
lobe may be rendered nearly solid, but there can usually be seen between 
the groups areas of crepitant air tissue. This is not an uncommon picture 
in the acute phthisis of adults, but it is still more frequent in children. 
The following is an extract from the post-mortem report of a case on a child 
aged four months, which died in the sixth week of illness: " On section, the 
right upper lobe is occupied with caseous masses from 5 to 12 mm. in diame- 
ter, separated from each other by an intervening tissue of a deep-red color. 
The bronchi are filled with cheesy substance. The middle and lower lobes 
are studded with tubercles, many of which are becoming caseous. Toward 
the diaphragmatic surface of the lower lobe there is a small cavity the size 
of a marble. The left lung is more crepitant and uniformly studded with 
tubercles of all sizes, some as large as peas. The bronchial glands are very 
large, and one contains a tuberculous abscess." 

There is a form of tuberculous aspiration pneumonia, to which Baum- 
ler has called attention, developing as a sequence of hemoptysis, and due 
to the aspiration of blood and the contents of pulmonary cavities into the 
finer tubes. Following the haemoptysis, which may have occurred in an 
individual without suspected lesion, there are fever, dyspnoea, and signs 
of a diffuse broncho-pneumonia. Some of these cases run a very rapid 
course, and are examples of galloping consumption following haemoptysis. 
This accident may occur not alone early in the disease, but may follow 
haemorrhage in a well-developed case of pulmonary tuberculosis. 

In children the enlarged bronchial glands usually surround the Toot of 
the lung, and even pass deeply into the substance, and the lobules are often 
involved by direct contact. 

In other cases the caseous broncho-pneumonia involves groups of alveoli 
or lobules in different portions of the lungs, more commonly at both 
apices, forming areas from 1 to 3 cm. in diameter. The size of the mass 
depends largely upon that of the bronchus involved. There are cases which 
probably should come in this category, in which, with a history of an acute 
illness of from four to eight weeks, the lungs are extensively studded with 
large gray tubercles, ranging in size from 5 to 10 mm. In some instances 
there are cheesy masses the size of a cherry. All of these are grayish-white 
in color, distinctly cheesy, and between the adjacent ones, particularly in 
the lower lobe, there may be recent pneumonia, or the condition of lung 
which has been termed splenization. In a case of this kind at the Phila- 
delphia Hospital death took place about the eighth week from the abrupt 
onset of the illness with haemorrhage. There were no extensive areas of 
consolidation, but the cheesy nodules were uniformly scattered throughout 
both lungs. No softening had taken place. 

Secondary infections are not uncommon; but Prudden was able to 



TUBERCULOSIS. 



293 



show that the tubercle bacillus could produce not only distinct tubercle 
nodules, but also the various kinds of exudative phenomena, the exudates 
varying in appearance in different cases, which phenomena occurred abso- 
lutely without the intervention of other organisms. The fact that these 
latter had not subsequently crept in was shown by cultures at the autopsy on 
the affected animal. 

Symptoms. — The symptoms of acute broncho-pneumonic phthisis 
are very variable. In adults the disease may attack persons in good health, 
but who are overworked or " run down " from any cause. Haemorrhage 
initiates the attack in a few cases. There may be repeated chills; the 
temperature is high, the pulse rapid, and the respirations are increased. 
The loss of flesh and strength is very striking. 

The physical signs may at first be uncertain and indefinite, but finally 
there are areas of impaired resonance, usually at the apices; the breath- 
sounds are harsh and tubular, with numerous rales. The sputa may early 
show elastic tissue and tubercle bacilli. In the acute cases, within three 
weeks, the patient may be in a marked typhoid state, with delirium, dry 
tongue, and high fever. Death may occur within three weeks. In other 
cases the onset is severe, with high fever, rapid loss of flesh and strength, 
and signs of extensive unilateral or bilateral disease. Softening takes place; 
there are sweats, chills, and progressive emaciation, and all the features of 
phthisis florida. Six or eight weeks later the patient may begin to im- 
prove, the fever lessens, the general symptoms abate, and a case which 
looks as if it would certainly terminate fatally within a few weeks drags 
on and becomes chronic. 

In children the disease most commonly follows the infectious diseases, 
particularly measles and whooping-cough.* The profession is gradually 
recognizing the fact that a majority of all such cases are tuberculous. 
At least three groups of these tuberculous broncho-pneumonias may be 
recognized. In the first the child is taken ill suddenly while teething 
or during convalescence from fever; the temperature rises rapidly, the 
cough is severe, and there may be signs of consolidation at one or both 
apices with rales. Death may occur within a few days, and the lung shows 
areas of broncho-pneumonia, with perhaps here and there scattered opaque 
grayish-yellow nodules. Macroscopically the affection does not look tuber- 
culous, but histologically miliary granulations and bacilli may be found. 
Tubercles are usually present in the bronchial glands, but the appearance 
of the broncho-pneumonia may be exceedingly deceptive, and it may re- 
quire careful microscopical examination to determine its tuberculous char- 
acter. The second group is represented by the case of the child previously 
quoted, which died at the sixth week with the ordinary symptoms of severe 
broncho-pneumonia. And the third group is that in which, during the 
convalescence from an infectious disease, the child is taken ill with fever, 
couo-h, and shortness of breath. The severity of the symptoms abates 
within the first fortnight; but there is loss of flesh, the general condition 
is bad, and the physical examination shows the presence of scattered rales 



* "Tussis convulsiva vcstibulum tabis" (Willis). 



294 



SPECIFIC INFECTIOUS DISEASES. 



throughout the lungs, and here and there areas of defective resonance. 
The child has sweats, the fever becomes hectic in character, and in many 
cases the clinical picture gradually develops into that of chronic phthisis. 

2. Chronic Ulcerative Tuberculosis of the Lungs. 

Under this heading may be grouped the great majority of cases of pul- 
monary tuberculosis, in which the lesions proceed to ulceration and soften- 
ing, and ultimately produce the well-known picture of chronic phthisis. 
At first a strictly tuberculous affection, it ultimately becomes, in a majority 
of cases, a mixed disease, many of the most prominent symptoms of which 
are due to septic infection from purulent foci and cavities. 

Morbid Anatomy. — Inspection of the lungs in a case of chronic 
phthisis shows a remarkable variety of lesions, comprising nodular tuber- 
cles, diffuse tuberculous infiltration, caseous masses, pneumonic areas, cavi- 
ties of various sizes, with changes in the pleura, bronchi, and bronchial 
glands. 

1. The Distribution of the Lesions. — For years it has been recognized 
that the most advanced lesions are at the apices, and that the disease pro- 
gresses downward, usually more rapidly in one of the lungs. This gen- 
eral statement, which has passed current in the text-books ever since the 
masterly description of Laennec, has recently been carefully elaborated 
by Kingston Fowler, who finds that the disease in its onward progress 
through the lungs follows, in a majority of the cases, distinct routes. In 
the upper lobe the primary lesion is not, as a rule, at the extreme apex, 
but from an inch to an inch and a half below the summit of the lung, and 
nearer to the posterior and external borders. The lesion here tends to 
spread downward, probably from inhalation of the virus, and this accounts 
for the frequent circumstance that examination behind, in the supra- 
spinous fossa, will give indications of disease before any evidences exist at 
the apex in front. Anteriorly this initial focus corresponds to a spot just 
below the centre of the clavicle, and the direction of extension in front 
is along the anterior aspect of the upper lobe, along a line running about 
an inch and a half from the inner ends of the first, second, and third inter- 
spaces. A second less common site of the primary lesion in the apex " cor- 
responds on the chest wall with the first and second interspaces below the 
outer third of the clavicle." The extension is downward, so that the outer 
part of the upper lobe is chiefly involved. 

In the middle lobe of the right lung the affection usually follows disease 
of the upper lobe on the same side. In the involvement of the lower lobe 
the first secondary infiltration is about an inch to an inch and a half below 
the posterior extremity of its apex, and corresponds on the chest wall to a 
' spot opposite the fifth dorsal spine. This involvement is of the greatest 
importance clinically, as " in the great majority of cases, when the physical 
signs of the disease at the apex are sufficiently definite to allow of the diag- 
nosis of phthisis being made, the lower lobe is already affected." Examina- 
tion, therefore, should be made carefully of this posterior apex in all sus- 
picious cases. In this situation the lesion spreads downward and laterally 



TUBERCULOSIS. 



295 



along the line of the interlobular septa, a line which is marked by the 
vertebral border of the scapula, when the hand is placed on the opposite 
scapula and the elbow raised above the level of the shoulder. Once pres- 
ent in an apex, the disease usually extends in time to the opposite upper 
lobe; but not, as a rule, until the apex of the lower lobe of the lung first 
affected has been attacked. 

Of 427 eases above mentioned, the right apex was involved in 172, the 
left in 130, both in 111. 

Lesions of the base may be primary, though this is rare. Percy Kidd 
makes the proportion of basic to apicic phthisis 1 to 500, a smaller number 
than existed in my series. In very chronic cases there may be arrested 
lesions at the apex and more recent lesions at the base. 

2. Summary of the Lesions in Chronic Ulcerative Phthisis. — (a) Mili- 
ary Tubercles. — They have one of two distributions: (1) A dissemination 
due to aspiration of tuberculous material, the tubercles being situated in the 
air-cells or the walls of the smaller bronchi; (2) the distribution due to 
dissemination of tubercle bacilli by the lymph current, the tubercles being 
scattered about the old foci in a radial manner — the secondary crop of 
Laennec. Much more rarely there is a scattered dissemination from in- 
fection here and there of the smaller vessels, the tubercles then being 
situated in the vessel walls. Sometimes, in cases with cavity formation at 
the apex, the greater part of the lower lobes presents many groups of firm, 
sclerotic, miliary tubercles, which may indeed form the distinguishing ana- 
tomical feature — a chronic miliary tuberculosis. 

(b) Tuberculous Broncho- pneumonia. — In a large proportion of the cases 
of chronic phthisis the terminal bronchiole is the point of origin of the 
process, consequently we find the smaller bronchi and their alveolar terri- 
tories blocked with the accumulated products of inflammation in all stages 
of caseation. At an early period a cross-section of an area of tuberculous 
broncho-pneumonia gives the most characteristic appearance. The central 
bronchiole is seen as a small orifice, or it is plugged with cheesy contents, 
while surrounding it is a caseous nodule, the so-called peribronchial tuber- 
cle. The longitudinal section has a somewhat dendritic or foliaceous ap- 
pearance. The condition of the picture depends much upon the slowness 
or rapidity with which the process has advanced. The following changes 
may occur: 

Ulceration. — When the caseation takes place rapidly or ulceration occurs 
in the bronchial wall, the mass may break down and form a small cavity. 

Sclerosis. — In other instances the process is more chronic. Fibroid 
changes gradually produce a sclerosis of the affected area, a condition 
which is sometimes called cirrhosis nodosa tuberculosa. The sclerosis may 
be confined to the margin of the mass, forming a limiting capsule, within 
which is a uniform, firm, cheesy substance, in which lime salts are often 
deposited. This represents the healing of one of these areas of caseous 
broncho-pneumonia. It is only, however, when complete fibroid trans- 
formation or calcification has occurred that we can really speak of healing. 
In many instances the colonies of miliary tubercles about these masses 
show that the virus is still active in them. Subsequently, in ulcerative 



296 



SPECIFIC INFECTIOUS DISEASES. 



processes, these calcareous bodies — lung-stones, as they are sometimes called 
— may be expectorated. 

(c) Pneumonia. — An important though secondary place is occupied 
by inflammation of the alveoli surrounding the tubercles, which become 
filled with epithelioid cells. The consolidation may extend for some dis- 
tance about the tuberculous foci and unite them into areas of uniform con- 
solidation. Although in some instances this inflammatory process may be 
simple, in others it is undoubtedly specific. It is excited by the tubercle 
bacilli and is a manifestation of their action. It may present a very varied 
appearance; in some instances resembling closely ordinary red hepatiza- 
tion, in others being more homogeneous and infiltrated, the so-called infil- 
tration tuberculeuse of Laennec. In other cases the contents of the alveoli 
undergo fatty degeneration, and appear on the cut surface as opaque white 
or yellowish-white bodies. In early phthisis much of the consolidation is 
due to this pneumonic infiltration, which may surround for some distance 
the smaller tuberculous foci. 

(d) Cavities. — A vomica is a cavity in the lung tissue, produced by 
necrosis and ulceration. It differs materially from the bronchiectatic form. 
The process usually begins in the wall of the bronchus in a tuberculous 
area. Dilatation is produced by retained secretion, and necrosis and ulcera- 
tion of the wall occur with gradual destruction of the contiguous tissues. 
By extension of the necrosis and ulceration the cavity increases, contigu- 
ous ones unite, and in an affected region there may be a series of small 
excavations communicating with a bronchus. In nearly all instances the 
process extends from the bronchi, though it is possible for necrosis and 
softening to take place in the centre of a caseous area without primary 
involvement of the bronchial wall. Three forms of cavities may be recog- 
nized. 

The fresli ulcerative, seen in acute phthisis, in which there is no limiting 
membrane, but the walls are made up of softened, necrotic, and caseous 
masses. Small vomicae of this sort, situated just beneath the pleura, may 
rupture and cause pneumothorax. In cases of acute tuberculo-pneumonic 
phthisis they may be large, occupying the greater portion of the upper 
lobe. In the chronic ulcerative phthisis, cavities of this sort are invariably 
present in those portions of the lung in which the disease is advancing. 
At the apex there may be a large old cavity with well-defined walls, while 
at the anterior margin of the upper lobes, or in the apices of the lower 
lobes, there are recent ulcerating cavities communicating with the bronchi. 

Cavities with Well-defined Walls. — A majority of the cavities in the 
chronic form of phthisis have a well-defined limiting membrane, the inner 
surface of which constantly produces pus. The walls are crossed by trabec- 
ular which represent remnants of bronchi and blood-vessels. Even the 
vomicae with the well-defined walls extend gradually by a slow necrosis 
and destruction of the contiguous lung tissue. The contents are usually 
purulent, similar in character to the grayish nummular sputa coughed up 
by phthisical patients. Not infrequently the membrane is vascular or it 
may be hsemorrhagic. Occasionally, when gangrene has occurred in the 
wall, the contents are horribly foetid. These cavities may occupy the greater 



TUBERCULOSIS. 



297 



portion of the apex, forming an irregular series which communicate with 
each other and with the bronchi, or the entire upper lobe except the an- 
terior margin may be excavated, forming a thin- walled cavity. In rare 
instances the process has proceeded to total excavation of the lung, not a 
remnant of which remains, except perhaps a narrow strip at the anterior 
margin. In a case of this kind, in a young girl, the cavity held 40 fluid 
ounces. 

Quiescent Cavities. — When quite small and surrounded by dense cica- 
tricial tissue communicating with the bronchi they form the cicatrices 
fistuleuses of Laennec. Occasionally one apex may be represented by a 
series of these small cavities, surrounded by dense fibrous tissue. The lin- 
ing membrane of these old cavities may be quite smooth, almost like a 
mucous membrane. Cavities of any size do not heal completely. 

Cases are often seen in which it has been supposed that a cavity has 
healed; but the signs of excavation are notoriously uncertain, and there 
may be pectoriloquy and cavernous sounds with gurgling, resonant rales 
in an area of consolidation close to a large bronchus. 

In the formation of vomicae the blood-vessels gradually become closed 
by an obliterating inflammation. They are the last structures to yield 
and may be completely exposed in a cavity, even when the circulation is 
still going on in them. Unfortunately, the erosion of a large vessel which 
has not yet been obliterated is by no means infrequent, and causes profuse 
and often fatal haemorrhage. Another common event is the development 
of aneurisms on the arteries running in the Avails of cavities. These may 
be small, bunch-like dilatations, or they may form sacs the size of a walnut 
or even larger. Easmussen, Douglas Powell, and others have called atten- 
tion to their importance in haemoptysis, under which section they are dealt 
with more fully. 

And finally, about cavities of all sorts, the connective tissue develops 
and tends to limit the extent. The thickening is particularly marked be- 
neath the pleura, and in chronic cases an entire apex may be converted into 
a mass of fibrous tissue, enclosing a few small cavities. 

(e) Pleura. — Practically, in all cases of chronic phthisis the pleura is 
involved. Adhesions take place which may be thin and readily torn, or 
dense and firm, uniting layers of from 2 to 5 mm. in thickness. This 
pleurisy may be simple, but in many cases it is tuberculous, and miliary 
tubercles or caseous masses are seen in the thickened membrane. Effusion 
is not at all infrequent, either serous, purulent, or haemorrhagic. Pneumo- 
thorax is a common accident. 

(f) Changes in the smaller oronclii control the situation in the early 
stages of tuberculous phthisis, and play an important role throughout the 
disease. The process very often begins in the walls of the smaller tubes 
and leads to caseation, distention with products of inflammation, and 
broncho-pneumonia of the lobules. In many cases the visible implication 
of the bronchus is an extension upward of a process which has begun in 
the smallest bronchiole. This involvement weakens the wall, leading to 
bronchiectasis, not an uncommon event in phthisis. The mucous mem- 
brane of the larger bronchi, which is usually involved in a chronic catarrh, 



298 



SPECIFIC INFECTIOUS DISEASES. 



is more or less swollen, and in some instances ulcerated. Besides these 
specific lesions, they may be the seat, especially in children, of inflamma- 
tion dne to secondary invasion, most frequently by the micrococcus lanceo- 
latus, with the production of a broncho-pneumonia. 

(g) The bronchial glands, in the more acute cases, are swollen and 
cedematous. Miliary tubercles and caseous foci are usually present. In 
cases of chronic phthisis the caseous areas are common, calcification may 
occur, and not infrequently purulent softening. 

(h) Changes in the other Organs. — Of these, tuberculosis is the most 
common. In my series of autopsies the brain presented tuberculous lesions 
in 31, the spleen in 33, the liver in 12, the kidneys in 32, the intestines 
in 65, and the pericardium in 7. Other groups of lymphatic glands besides 
the bronchial may be affected. 

Certain degenerations are common. Amyloid change is frequent in 
the liver, spleen, kidneys, and mucous membrane of the intestines. The 
liver is often the seat of extensive fatty infiltration, which may cause 
marked enlargement. The intestinal tuberculosis occurs in advanced cases 
and is responsible in great part for the troublesome diarrhoea. 

Endocarditis is not very uncommon, and was present in 12 of my post 
mortems and in 27 of Percy Kidd's 500 cases. Tubercle bacilli have been 
found in the vegetations. The subject has been considered in an impor- 
tant monograph by Teissier (Paris, 1894). Tubercles may be present on 
the endocardium, particularly of the right ventricle. As pointed out by 
Norman Chevers, and confirmed by subsequent writers, the subjects of 
congenital stenosis of the pulmonary orifice very frequently have phthisis. 

The larynx is frequently involved, and ulceration of the vocal cords 
and destruction of the epiglottis are not at all uncommon. 

Modes of Onset. — We have already seen that tuberculosis of the 
lungs may occur as the chief part of a general infection, or may set in 
with symptoms which closely simulate acute pneumonia. In the ordinary 
type of pulmonary tuberculosis the invasion is gradual and less striking, 
but presents an extraordinarily diverse picture, so that the practitioner is 
often led into error. Among the most characteristic of these types of onset 
are the following: 

(a) There is a small but important group of cases in which the disease 
makes considerable progress before there are serious symptoms to arouse 
the attention of the patient. This latent form of the disease is seen most 
frequently in workingmen, and the disease may even advance to excava- 
tion of an apex before they seek advice. In some of these cases it is not a 
little remarkable how slight the lung symptoms have been. 

A different type of latent pulmonary tuberculosis is the form in which 
the symptoms are masked by the existence of serious disease in other organs, 
as in the peritonaeum, intestines, or bones. 

(b) With Symptoms of Dyspepsia and Ancemia. — The gastric mode of 
onset is very common, and the early manifestations may be great irritability 
of the stomach with vomiting or a type of acid dyspepsia with eructa- 
tions. In young girls (and in children) with this dyspepsia there is very 
frequently a pronounced chloro-anaemia, and the patient complains of pal- 



TUBERCULOSIS. 



299 



pitation of the heart, increasing weakness, slight afternoon fever, and 
amenorrhcea. 

(c) In a considerable number of cases the onset of pulmonary tuber- 
culosis is with symptoms which suggest malarial fever. The patient has 
repeated paroxysms of chills, fevers, and sweats, which may recur with 
great regularity. In districts in which intermittents prevail there is no 
more common mistake than to confound the initial rigors of pulmonary 
tuberculosis with malaria. 

(d) Onset with Pleurisy. — The first symptoms may be a dry pleurisy 
over an apex, with persistent friction murmur. In other instances the 
pulmonary symptoms have followed an attack of pleurisy with effusion. 
The exudate gradually disappears, but the cough persists and the pa- 
tient becomes feverish, and gradually signs of disease at one apex become 
manifest. Of 90 cases of pleurisy with effusion, the history of which 
was followed by H. I. Bowditch, one third developed pulmonary tuber- 
culosis. 

(e) With Laryngeal Symptoms. — The primary localization may be in 
the larynx, though in a majority of the instances in which huskiness and 
laryngeal symptoms are the first noticeable features of the disease there 
are doubtless foci already existing in the lung. The group of cases in 
which for many months throat and larynx symptoms precede the graver 
manifestations of pulmonary phthisis is a very important one. 

(/) Onset with Haemoptysis. — Frequently the very first symptom of 
the disease is a brisk haemorrhage from the lungs, following which the pul- 
monary symptoms may develop with great rapidity. In other cases the 
haemoptysis recurs, and it may be months before the symptoms become 
well established. In a majority of these cases the local tuberculous lesion 
exists at the date of the haemoptysis. 

(g) With Tuberculosis of the C ervico-axitlary Glands. — Preceding the 
onset of pulmonary phthisis for months, or even for years, the lymph- 
glands of the neck or of the neck and axilla of one side may be enlarged. 
These cases are by no means infrequent, and they are of importance be- 
cause of the latency of the pulmonary lesions. Nowadays, when operative 
interference is so common, it is well to bear in mind that in such patients 
the corresponding apex of the lung may be extensively involved. 

(h) And, lastly, in by far the largest number of all cases the onset is 
with a bronchitis, or, as the patient expresses it, a neglected cold. There 
has been, perhaps, a liability to catch cold easily or the patient has been 
subject to naso-pharyngeal catarrh; then, following some unusual exposure, 
a bronchial cough develops, which may be frequent and very irritating. 
The examination of the lungs may reveal localized moist sounds at one 
apex and perhaps wheezing bronchitic rales in other parts. In a few cases 
the early symptoms are often suggestive of asthma with marked wheezing 
and diffuse piping rales. 

Symptoms. — In discussing the symptoms it is usual to divide the 
disease into three periods: the first embracing the time of the growth and 
development of the tubercles; the second, in which they soften; and the 
third, in which there is a formation of cavities. Unfortunately, these ana- 
19 



300 



SPECIFIC INFECTIOUS DISEASES. 



tomical stages cannot be satisfactory correlated with corresponding clinical 
periods, and we often find that a patient in the third stage with well- 
marked cavity is in a far better condition and has greater prospects of re- 
covery than a patient in the first stage with diffuse consolidation. It is 
therefore better perhaps to disregard them altogether. 

1. Local Symptoms. — Pain in the chest may be early and troublesome 
or absent throughout. It is usually associated with pleurisy, and may be 
sharp and stabbing in character, and either constant or felt only during 
coughing. Perhaps the commonest situation is in the lower thoracic zone, 
though in some instances it is beneath the scapula or referred to the apex. 
The attacks may recur at long intervals. Intercostal neuralgia occasionally 
develops in the course of ordinary phthisis. 

Cough is one of the earliest symptoms, and is present in the majority 
of cases from beginning to end. There is nothing peculiar or distinctive 
about it. At first dry and hacking, and perhaps scarcely exciting the atten- 
tion of the patient, it subsequently becomes looser, more constant, and 
associated with a glairy, muco-purulent expectoration. In the early stages 
of the disease the cough is bronchial in its origin. When cavities have 
formed it becomes more paroxysmal, and is most marked in the morning 
or after a sleep. Cough is not a constant symptom, however, and a patient 
may present himself with well-marked excavation at one apex who will 
declare that he has had little or no cough. So, too, there may be well- 
marked physical signs, dulness and moist sounds, without either expectora- 
tion or cough. In well-established cases the nocturnal paroxysms are most 
distressing and prevent sleep. The cough may be of such persistence and 
severity as to cause vomiting, and the patient becomes rapidly emaciated 
from loss of food — Morton's cough (Phthisiologia, 1689, p. 101). The 
laryngeal complications give a peculiarly husky quality to the cough, and 
when erosion and ulceration have proceeded far in the vocal cords the 
efforts of coughing are much less effective. 

Sputum. — This varies greatly in amount and character at the different 
stages of ordinary phthisis. There are cases with well-marked local signs 
at one apex, with slight cough and moderately high fever, without from 
day to day a trace of expectoration. So, also, there are instances with the 
most extensive consolidation (caseous pneumonia), and high fever, but, as 
in a recent instance under observation for several months, without enough 
expectoration to enable an examination for bacilli to be made. In the 
early stage of pulmonary tuberculosis the sputum is chiefly catarrhal and 
has a glairy, sago-like appearance, due to the presence of alveolar cells 
which have undergone the myelin degeneration. There is nothing dis- 
tinctive or peculiar in this form of expectoration, which may persist for 
months without indicating serious trouble. The earliest trace of charac- 
teristic sputum may show the presence of small grayish or greenish-gray 
purulent masses. These, when coughed up, are always suggestive and 
should be the portions picked out for microscopical examination. As 
softening comes on, the expectoration becomes more profuse and puru- 
lent, but may still contain a considerable quantity of alveolar epithelium. 
Finally, when cavities exist, the sputa assume the so-called nummular 



TUBERCULOSIS. 301 

form; each mass is isolated, flattened, greenish-gray in color, quite airless, 
and sinks to the bottom when spat into water. 

By the microscopical examination of the sputum we determine whether 
the process is tuberculous, and whether softening has occurred. For tubercle 
bacilli the Ehrlich-Weigert method is the best. Eleven centimetres of a 
saturated solution of fuchsin in absolute alcohol is added to 100 cc. of 
the saturated solution of commercial aniline oil (made by shaking up the 
oil in water and then filtering). This should be made fresh every third 
or fourth day. A small bit of the sputum is picked out on a needle or 
platinum wire and spread thin on the top-cover so as to make a uniformly 
thin layer. The top-cover is slowly dried about a foot above a Bunsen 
burner. Sufficient of the staining fluid is then dropped upon the top- 
cover, which is held at a little distance above the flame until the fluid 
boils. The staining fluid is then washed off in distilled water or put under 
the tap, decolorized in 30 per cent nitric-acid fluid, again washed off in 
water, and mounted on the slide. In doubtful cases the long process is 
used, the cover-slips remaining twenty-four hours in the stain. The bacilli 
are seen as elongated, slightly curved, red rods, sometimes presenting a 
beaded appearance. They are frequently in groups of three or four, but 
the number varies considerably. Only one or two may be found in a prep- 
aration, or, in some instances, they are so abundant that the entire field is 
occupied. 

The presence of these bacilli in the sputum is an infallible indication of 
the existence of tuberculosis. 

Sometimes they are found only after repeated examination. They may 
be abundant early in the disease and are usually numerous in the num- 
mular sputum of the later stages. 

Elastic tissue may be derived from the bronchi, the alveoli, or from 
the arterial coats; and naturally the appearance of the tissue will vary with 
the locality from which it comes. In the examination for this it is not 
necessary to boil the sputum with caustic potash. For years I have used 
a simple plan which was shown to me at the London Hospital by Sir 
Andrew Clark. This method depends upon the fact that in almost all 
instances if the sputum is spread in a sufficiently thin layer the fragments 
of elastic tissue can be seen with the naked eye. The thick, purulent por- 
tions are placed upon a glass plate 15 X 15 cm. and flattened into a thin 
layer by a second glass plate 10 X 10 cm. In this compressed grayish layer 
between the glass slips any fragments of elastic tissue show on a black 
background as grayish-yellow spots and can either be examined at once 
under a low power or the uppermost piece of glass is slid along until the 
fragment is exposed, when it is picked out and placed upon the ordinary 
microscopic slide. Fragments of bread and collections of milk-globules 
may also present an opaque white appearance, but with a little practice they 
can readily be recognized. Fragments of epithelium from the tongue, 
infiltrated with micrococci, are still more deceptive, but the microscope at 
once shows the difference. 

The bronchial elastic tissue forms an elongated network, or two or 
three long, narrow fibres are found close together. From the blood-vessels 



302 



SPECIFIC INFECTIOUS DISEASES. 



a somewhat similar form may be seen and occasionally a distinct sheeting 
is found as if it had come from the intima of a good-sized artery. The 
elastic tissue of the alveolar wall is quite distinctive; the fibres are branched 
and often show the outline of the arrangement of the air-cells. The elastic 
tissue from bronchus or alveoli indicates extensive erosion of a tube and 
softening of the lung-tissue. 

Another occasional constituent of the sputum is blood, which may be 
present as the chief characteristic of the expectoration in haemoptysis or 
may simply tinge the sputum. In chronic cases with large cavities, in 
addition to bacteria, various forms of fungi may develop, of which the 
aspergillus is the most important. Sarcinae may also occur. 

Calcareous Fragments. — Formerly a good deal of stress was laid upon 
their presence in the sputum, and Morton described a phthisis a calculis in 
pulmonibus generatis. Bayle also described a separate form of plithisie cal- 
culeuse. The size of the fragments varies from a small pea to a large cherry. 
As a rule, a single one is ejected; sometimes large numbers are coughed 
up in the course of the disease. They are formed in the lung by the calci- 
fication of caseous masses, and it is said also occasionally in obstructed 
bronchi. They may come from the bronchial glands by ulceration into 
the bronchi, and there is a case on record of suffocation in a child from 
this cause. 

The daily amount of expectoration varies. In rapidly advancing cases, 
with much cough, it may reach as high as 500 cc. in the day. In cases with 
large cavities the chief amount is brought up in the morning. The ex- 
pectoration of tuberculous patients usually has a heavy, sweetish odor, and 
occasionally it is fetid, owing to decomposition in the cavities. 

Haemoptysis. — One of the most famous of the Hippocratic axioms 
says, " From a spitting of blood there is a spitting of pus." The older 
writers thought that the phthisis was directly due to the inflammatory 
or putrefactive changes caused by the haemorrhage into the lung. Morton, 
however, in his interesting section, Phthisis ab Haemoptoe, rather doubted 
this sequence. Laennec and Louis, and later in the century Traube, re- 
garded the haemoptysis as an evidence of existing disease of the lung. From 
the accurate views of Laennec and Louis the profession was led away by 
Graves, and particularly by Niemeyer, who held that the blood in the air- 
cells set up an inflammatory process, a common termination of which was 
caseation. Since Koch's discovery we have learned that many cases in 
which the physical examination is negative show, either during the period 
of haemorrhage or immediately after it, tubercle bacilli in the sputa, so that 
opinion has veered to the older view, and we now regard the appearance of 
haemoptysis as an indication of existing disease. In young, apparently 
healthy persons, cases of haemoptysis may be divided into three groups. In 
the first the bleeding has come on without premonition, without over- 
exertion or injury, and there is no family history of tuberculosis. The 
physical examination is negative, and the examination of the expectoration 
at the time of the haemorrhage and subsequently shows no tubercle bacilli. 
Such instances are not uncommon, and, though one may suspect strongly 
the presence of some focus of tuberculosis, yet the individuals may retain 



TUBERCULOSIS. 



303 



good health for many years, and have no further trouble. Of the 386 cases 
of haemoptysis noted by Ware in private practice, 62 recovered, and pul- 
monary disease did not subsequently develop. 

In a second group individuals in apparently perfect health are sud- 
denly attacked, perhaps after a slight exertion or during some athletic 
exercises. The physical examination is also negative, but tubercle bacilli 
are found sometimes in the bloody sputa, more frequently a few days later. 

In a third set of cases the individuals have been in failing health for 
a month or two, but the symptoms have not been urgent and perhaps not 
noticed by the patients. The physical examination shows the presence of 
well-marked tuberculous disease, and there are both tubercle bacilli and 
elastic tissue in the sputa. 

A very interesting systematic study of the subject of haemoptysis, par- 
ticularly in its relation to the question of tuberculosis, has been completed 
in the Prussian army by Franz Strieker. During the five years 1890- , 95 
there were 900 cases admitted to the hospitals, which is a percentage of 
0.045 of the strength (1,728,505). Of the cases, in 480 the haemorrhage 
came on without recognizable cause. Of these 417 cases, 86 per cent were 
certainly or probably tuberculous. In only 221, however, was the evidence 
conclusive. 

In a second group of 213 cases the haemorrhage came on during the 
military exercise, and of these 75 patients were shown to be tuberculous. 

In 118 cases the haemorrhage followed certain special exercises, as in 
the gymnasium or in riding or in consequence of swimming. In 24 cases 
it developed during the exercise of the voice in singing or in giving com- 
mand or in the use of wind instruments. A very interesting group is re- 
ported of 24 cases in which the haemorrhage followed trauma, either a fall 
or a blow upon the thorax. In 7 of these tuberculosis was positively pres- 
ent, and in 6 other cases there was a strong probability of its existence. 

Among the conclusions which Strieker draws the following are the 
most important: namely, that soldiers attacked with haemoptysis without 
special cause are in at least 86.8 per cent tuberculous. In the cases in 
which the haemoptysis follows the special exercises, etc., of military serv- 
ice, at least 74.4 per cent are tuberculous. In the cases which come on 
during swimming or as a consequence of direct injury to the thorax about 
one half are not associated with tuberculosis. 

Haemoptysis occurs in from 60 to 80 per cent of all cases of pulmonary 
tuberculosis. It is more frequent in males than in females. 

In a majority of all cases the bleeding recurs. Sometimes it is a special 
feature throughout the disease, so that a haemorrhagic or haemoptysieal 
form has been recognized. The amount of blood brought up varies from 
a couple of drachms to a pint or more. In 69 per cent of 4,125 cases of 
haemoptysis at the Brompton Hospital the amount brought up was under 
half an ounce. 

A distinction may be drawn between the haemoptysis early in the dis- 
ease and that which occurs in the later periods. In the former the bleed- 
ing is usually slight, is apt to recur, and fatal haemorrhage is very rare. In 
these instances the bleeding is usually from small areas of softening or 



304 



SPECIFIC INFECTIOUS DISEASES. 



from early erosions in the bronchial mucosa. In the later periods, after 
cavities have formed, the bleeding is, as a rule, more profuse and is more 
apt to be fatal. Single large haemorrhages, proving quickly fatal, are very 
rare, except in the advanced stages of the disease. In these cases the bleed- 
ing comes either from an erosion of a good-sized vessel in the wall of a 
cavity or from the rupture of an aneurism of the pulmonary artery. 

The bleeding, as a rule, sets in suddenly. Without any warning the 
patient may notice a warm salt taste and the mouth fills with blood. It 
may come up with a slight cough. The total amount may not be more 
than a few drachms, and for a day or two the patient may spit up small 
quantities. When a large vessel is eroded or an aneurism bursts, the amount 
of blood brought up is large, and in the course of a short time a pint or 
two may be expectorated. Fatal haemorrhage may occur into a very large 
cavity without any blood being coughed up. The character of the blood is, 
as a rule, distinctive. It is frothy, mixed with mucus, generally bright red 
in color, except when large amounts are expectorated, and then it may be 
dark. The sputa may remain blood-tinged for some days or there are 
brownish-black streaks in the sputa, or " friable nodules consisting entirely 
of blood-corpuscles 93 may be coughed up. Blood moulds of the smaller 
bronchi are sometimes expectorated. 

The microscopical examination of the sputum in tuberculous cases 
is most important. If carefully spread out, there may be noted, even in an 
apparently pure haemorrhagic mass, little portions of mucus from which 
bacilli or elastic tissue may be obtained. 

Dyspnoea is not a common accompaniment of ordinary phthisis. The 
greater part of one lung may be diseased and local trouble exist at the 
other apex without any shortness of breath. Even in the paroxysms of 
very high fever the respirations may not be much increased. Eapid ad- 
vance of a broncho-pneumonia, or the development of miliary tubercles 
throughout the lung, causes great increase in the number of respirations. 
A degree of dyspnoea leading to cyanosis is almost unknown, apart from 
extensive invasion of the sound portions by miliary tubercles. 

In long standing cases, with contracted apices or great thickening of 
the pleura, the right heart is enlarged, and the dyspnoea may be cardiac. 

2. General Symptoms. — Fever. — To get a correct idea of the tempera- 
ture range in pulmonary tuberculosis it is necessary, * as Einger pointed 
out, to make tolerably frequent observations. The usual 8 a. m. and 8 p. m. 
record is, in a majority of the cases, very deceptive, giving neither the 
minimum nor maximum. The former usually occurs between 2 and 6 a. m. 
and the latter between 2 and 6 p. m. 

A recognition of various forms of fever, viz., of tuberculization, of 
ulceration, and of absorption, emphasizes the anatomical stages of growth, 
softening and cavity formation; but practically such a division is of little 
use, as in a majority of cases these processes are going on together. 

Fever is the most important initial symptom and throughout the entire 
course the thermometer is the most trustworthy guide as to the progress 
of the affection. With pyrexia a patient loses in weight and strength, 
and the local disease usually progresses. The periods of apyrexia are those 



TUBERCULOSIS. 



305 



of gain in weight and strength and of limitation of the local lesion. It by 
no means necessarily follows that a patient with tuberculosis has pyrexia. 
There may be quite extensive disease without coexisting fever. At one time, 
I have had 18 instances of chronic phthisis under observation, of whom 
10 were practically free from fever. But in the early stage, when tubercles 
are developing and caseous areas are in process of formation and when 
softening is in progress, fever is a constant symptom. It was present in 
100 consecutive cases in my dispensary service. 

Two types of fever are seen — the remittent and the intermittent. These 
may occur indifferently in the early or in the late stages of the disease 




Chart XII. Three days. Chronic tuberculosis. 



or may alternate with each other, a variability which depends upon the 
fact that phthisis is a progressive disease and that all stages of lesions may 
be found in a single lung. Special stress should be laid upon the fact, 
particularly in malarial regions, that tuberculosis may set in with a fever 
typically intermittent in character — a daily chill, with subsequent fever 
and sweat. In Montreal, where malaria is practically unknown, this was 
always regarded as a suggestive symptom; but in Philadelphia and Balti- 



306 



SPECIFIC INFECTIOUS DISEASES. 



more, where ague prevails, it is no exaggeration to say that yearly scores 
of eases of early tuberculosis are treated for ague. These are often cases 
that pursue a rapid course. The fever of onset — tuberculization — may be 
almost continuous, with slight daily exacerbations; and at any time during 
the course of chronic phthisis, if there is rapid extension, the remissions 
become less marked. 

A remittent fever, in which the temperature is constantly above normal 
but drops two or three degrees toward morning, is not uncommon in the 
middle and later stages and is usually associated with softening or exten- 
sion of the disease. Here, too, a simple morning and evening register may 
give an entirely erroneous idea as to the range of the fever. With break- 
ing down of the lung-tissue and formation of cavities, associated as these 
processes always are with suppuration and with more or less systemic con- 
tamination, the fever assumes a characteristically intermittent or hectic 
type. For a large part of the day the patient is not only afebrile, but the 
temperature is subnormal. In the annexed two-hourly chart, from a case 
of chronic tuberculosis of the lungs, it will be seen that from 10 p. M. to 
8 a. m. or noon, the temperature continuously fell and went as low as 95°. 
A slow rise then took place through the late morning and early afternoon 
hours and reached its. maximum between 6 and 10 p. m. As shown in the 
chart, there were in the three days about forty-three hours of pyrexia and 
twenty-nine hours of apyrexia. The rapid fall of the temperature in the 
early morning hours is usually associated with sweating. This hectic, as 
it is called, which is a typical fever of septic infection, is met with when 
the process of cavity formation and softening is advanced and extending. 

A continuous fever with remissions of not more than a degree, develop- 
ing in the course of pulmonary tuberculosis, is suggestive of acute pneu- 
monia. When a two-hourly chart is made, the remissions even in acute 
tuberculous pneumonia are usually well marked. A continued fever, such 
as is seen in the first week of typhoid, or in some cases of inflammation of 
the lung, is rare in tuberculosis. 

Sweating. — Drenching perspirations are common in phthisis and con- 
stitute one of the most distressing features of the disease. They occur usu- 
ally with the drop in the fever in the early morning hours, or at any time 
in the day when the patient sleeps. They may come on early in the disease, 
but are more persistent and frequent after cavities have formed. Some 
patients escape altogether. 

The pulse is increased in frequency, especially when the fever is high. 
It is often remarkably full, though soft and compressible. Pulsation may 
sometimes be seen in the capillaries and in the veins on the back of the 
hand. 

Emaciation is a pronounced feature, from which the two common names 
of the disease have been derived. The loss of weight is gradual but, if the 
disease is extending, progressive. The scales give one of the best indica- 
tions of the progress of the case. 

3. Physical Signs. — (a) Inspection, — The shape of the chest is often 
suggestive, though it is to be remembered that pulmonary tuberculosis may 
be met with in chests of any build. Practically, however, in a consider- 



TUBERCULOSIS. 



307 



able proportion of cases the thorax is long and narrow, with very wide 
intercostal spaces, the ribs more vertical in direction and the costal angle 
very narrow. The scapulae are " winged," a point noted by Hippocrates. 
Another type of chest which is very common is that which is flattened in 
the antero-posterior diameter. The costal cartilages may be prominent 
and the sternum depressed. Occasionally the lower sternum forms a deep 
concavity, the so-called funnel breast (Trichter-Brust). Inspection gives 
valuable information in all stages of the disease. Special examination 
should be made of the clavicular regions to see if one clavicle stands out 
more distinctly than the other, or if the spaces above or below it are more 
marked. Defective expansion at one apex is an early and important sign. 
The condition of expansion of the lower zone of the thorax may be well 
estimated by inspection. The condition of the pragcordia should also be 
noted, as a wide area of impulse, particularly in the second, third, and 
fourth interspaces, often results from disease of the left apex. From a point 
behind the patient, looking over the shoulders, one can often better esti- 
mate the relative expansion of the apices. 

(b) Palpation. — Deficiency in expansion at the apices or bases is per- 
haps best gauged by placing the hands in the subclavicular spaces and then 
in the lateral regions of the chest and asking the patient to draw slowly a 
full breath. Standing behind the patient and placing the thumbs in the 
supraclavicular and the fing'ers in the infraclavicular spaces one can judge 
accurately as to the relative mobility of the two sides. Disease at an apex, 
though early and before dulness is at all marked, may be indicated by 
deficient expansion. On asking the patient to count, the tactile fremitus 
is increased wherever there is local growth of tubercle or extensive casea- 
tion. In comparing the apices it is important to bear in mind that normally 
the fremitus is stronger over the right than the left. So too at the base, 
when there is consolidation of the lung, the fremitus is increased; whereas, 
if there is pleural effusion, it is diminished or absent. In the later stages, 
when cavities form, the tactile fremitus is usually much exaggerated over 
them. When the pleura is greatly thickened the fremitus may be somewhat 
diminished. 

(c) Percussion. — Tubercles, inflammatory products, fibroid changes, 
and cavities produce important changes in the pulmonary resonance. 
There may be localized disease, even of some extent, without inducing 
much alteration; as when the tubercles are scattered and have air-contain- 
ing tissue between them. One of the earliest and most valuable signs is 
defective resonance upon and above a clavicle. In a considerable propor- 
tion of all cases of phthisis the dulness is first noted in these regions. The 
comparison between the two sides should be made also when the breath 
is held after a full inspiration, as the defective resonance may then be 
more clearly marked. In the early stages the percussion note is usually 
higher in pitch, and it may require an experienced ear to detect the differ- 
ence. In recent consolidation from caseous pneumonia the percussion note 
often has a tubular or tympanitic quality. A wooden dulness is rarely 
heard except in old cases with extensive fibroid change at the apex or base. 
Over large, thin-walled cavities at the apex the so-called cracked-pot sound 



308 



SPECIFIC INFECTIOUS DISEASES. 



may be obtained. In thin subjects the percussion should be carefully prac- 
tised in the supraspinous fossae and the interscapular space, as they cor- 
respond to very important areas early involved in the disease. In cases 
with numerous isolated cavities at the apex, without much fibroid tissue 
or thickening of the pleura, the percussion note may show little change, 
and the contrast between the signs obtained on auscultation and percussion 
is most marked. In the direct percussion of the chest, particularly in thin 
patients over the pectorals, one frequently sees the phenomenon known 
as myoidema, a local contraction of the muscle causing bulging, which per- 
sists for a variable period and gradually subsides. It has no special signifi- 
cance. 

(d) Auscultation. — Feeble breath-sounds are among the most charac- 
teristic early signs, since not as much air enters the tubes and vesicles of 
the affected area. It is well at first always to compare carefully the cor- 
responding points on the two sides of the chest without asking the patient 
either to draw a deep breath or to cough. With early apical disease the 
inspiration on quiet breathing may be scarcely audible. Expiration is 
usually prolonged. On the other hand, there are cases in which the earliest 
sign is a harsh, rude, respiratory murmur. On deep breathing it is fre- 
quently to be noted that inspiration is jerking or wavy, the so-called " cog- 
wheel " rhythm; which, however, is by no means confined to tuberculosis. 
With extension of the disease the inspiratory murmur is harsh, and, when 
consolidation occurs, whiffing and bronchial. With these changes in the 
character of the murmur there are rales, due to the accompanying bron- 
chitis. They may be heard only on deep inspiration or on coughing, and 
early in the disease are often crackling in character. When softening 
occurs they are louder and have a bubbling, sometimes a characteristic 
clicking quality. These " moist sounds," as they are called, when asso- 
ciated with change in the percussion resonance are extremely suggestive. 
When cavities form, the rales are louder, more gurgling, and resonant in 
quality. When there is consolidation of any extent the breath-sounds are 
tubular, and in the large excavations loud and cavernous, or have an am- 
phoric quality. In the unaffected portions of the lobe and in the opposite 
lung the breath-sounds may be harsh and even puerile. The vocal reso- 
nance is usually increased in all stages of the process, and bronchophony 
and pectoriloquy are met with in the regions of consolidation and over 
cavities. Pleuritic friction may be present at any stage and, as mentioned 
before, occurs very early. There are cases in which it is a marked feature 
throughout. When the lappet of lung over the heart is involved there 
may be a pleuro-pericardial friction, and when this area is consolidated 
there may be curious clicking rales synchronous with the heart-beat, due 
to the compression by the heart of, and the expulsion of air from, this 
portion. An interesting auscultatory sign, met most commonly in phthisis, 
is the so-called cardio-respiratory murmur, a whiffing systolic bruit due 
to the propulsion of air out of the tubes by the impulse of the heart. 
It is best heard during inspiration and in the antero-lateral regions of the 
chest. 

A systolic murmur is frequently heard in the subclavian artery on either 



TUBERCULOSIS. 



309 



side, the pulsation of which may be very visible. The murmur is in all 
probability due to pressure on the vessels by the thickened pleura. 

The signs of cavity may be here briefly enumerated. 

(a) When there is not much thickening of the pleura or condensation 
of the surrounding lung-tissue, the percussion sound may be full and clear, 
resembling the normal note. More commonly there is defective resonance 
or a tympanitic quality which may at times be purely amphoric. The pitch 
of the percussion note changes over a cavity when the mouth is opened or 
closed (Wintrich's sign), or it may be brought out more clearly on change 
of position. The cracked-pot sound is only obtainable over tolerably large 
cavities with thin walls. It is best elicited by a firm, quick stroke, the 
patient at the time having the mouth open. In those rare instances of 
almost total excavation of one lung the percussion note may be amphoric 
in quality, (b) On auscultation the so-called cavernous sounds are heard: 
(1) Various grades of modified breathing — blowing or tubular, cavernous 
or amphoric. There may be a curiously sharp hissing sound, as if the air 
was passing from a narrow opening into a wide space. In very large cavi- 
ties both inspiration and expiration may be typically amphoric. (2) There 
are coarse bubbling rales which have a resonant quality, and on coughing 
may have a metallic or ringing character. On coughing they are often loud 
and gurgling. In very large thin-walled cavities, and more rarely in 
medium-sized cavities, surrounded by recent consolidation, the rales may 
have a distinctly amphoric echo, simulating those of pneumothorax. There 
are dry cavities in which no rales are heard. (3) The vocal resonance is 
greatly intensified and whispered pectoriloquy is clearly heard. In large 
apical cavities the heart-sounds are well heard, and occasionally there may 
be an intense systolic murmur, probably always transmitted to, and not 
produced as has been supposed, in the cavity itself. In large excavations 
of the left apex the heart impulse may cause gurgling sounds or clicks 
synchronous with the systole. They may even be loud enough to be heard 
at a little distance from the chest wall. A large cavity with smooth walls 
and thin fluid contents may give the succussion sound when the trunk is 
abruptly shaken (Walshe), and even the coin sound may be obtained. 

Pseudo-cavernous signs may be caused by an area of consolidation near 
a large bronchus. The condition may be most deceptive — the high-pitched 
or tympanitic percussion note, the tubular or cavernous breathing, and the 
resonant rales, simulate closely those of cavity. 

4. Complications of Pulmonary Tuberculosis.— (1) In the 
Respiratory System. — The larynx is rarely spared in chronic pulmonary 
tuberculosis. The first symptom may be huskiness of the voice. There 
are pain, particularly in swallowing, and a cough which is often wheezing, 
and in the later stages very ineffectual. Aphonia and dysphagia are the 
two most distressing symptoms of the laryngeal involvement. When the 
epiglottis is seriously diseased and the ulceration extends to the lateral 
wall of the pharynx, the pain in swallowing may be very intense, or, owing 
to the imperfect closure of the glottis, there may be coughing spells and 
regurgitation of food through the nostrils. Bronchitis and tracheitis are 
almost invariable accompaniments of chronic pulmonary tuberculosis. 



310 



SPECIFIC INFECTIOUS DISEASES. 



Pneumonia is a not infrequent terminal complication of chronic 
phthisis. It may run a perfectly normal course, while in other instances 
resolution may be delayed, and one is in doubt, in spite of the abruptness 
of the onset, as to the presence of a simple or a tuberculous pneumonia. 

Emphysema of the uninvolved portions of the lung is a common fea- 
ture, rarely producing any special symptoms. There are, however, cases 
of chronic tuberculosis in which emphysema dominates the picture, and 
in which the condition develops slowly during a period of many years. 
(General subcutaneous emphysema, which has been met with in a few 
rare cases, is due either to perforation of the trachea or to the rupture of 
a cavity closely adherent to the chest wall.) 

Gangrene of the lung is an occasional event in chronic pulmonary 
tuberculosis, due in almost all instances to sphacelus in the walls of the 
cavity, rarely in the lung-tissue itself. 

Complications in the Pleura. — A dry pleurisy is a very common accom- 
paniment of the early stages of tuberculosis. It is always a conservative, 
useful process. In some cases it is very extensive, and friction murmurs 
may be heard over the sides and back. The cases with dry pleurisy and 
adhesions are of course much less liable to the dangers of pneumothorax. 
Pleurisy with effusion more commonly precedes than develops in the course 
of pulmonary tuberculosis. Still, it is common enough to meet with cases 
in which a sero-flbrinous effusion develops in the course of the chronic 
disease. There are cases in which it is a special feature, and it often, I think, 
favors chronicity. A patient may during a period of four or five years 
have signs of local disease at one apex with recurring effusion in the same 
side. Owing to adhesions in different parts of the pleura, the effusion may 
be encapsulated. Hemorrhagic effusions, which are not uncommon in 
connection with tuberculous pleurisy, are comparatively rare in chronic 
phthisis. Chyliform or milky exudates are sometimes found. Purulent 
effusions are not frequent apart from pneumothorax. An empyema, how- 
ever, may develop in the course of the disease or as a sequence of a sero- 
fibrinous exudate. Pneumothorax is an extremely common complication 
of chronic pulmonary tuberculosis. It may occur early in the disease, but 
more frequently is late. It may prove fatal in twenty-four hours. In 
other instances a pyo-pneumothorax develops and the patient lingers for 
weeks or months. In a third group of cases it seems to have a beneficial 
effect on the course of the disease. 

(2) Symptoms referable to other Organs. — (a) Cardio-vascular. — The 
retraction of the left upper lobe exposes a large area of the heart. In thin- 
chested subjects there may be pulsation in the second, 'third, and fourth 
interspaces close to the sternum. Sometimes with much retraction of the 
left upper lobe the heart is drawn up. A systolic murmur over the pul- 
monary area is common in all stages of phthisis. Apical murmurs are also 
not infrequent and may be extremely rough and harsh without necessarily 
indicating that endocarditis is present. The association of heart-disease 
with phthisis is not, however, very uncommon. As already mentioned, 
there were 12 instances of endocarditis in 216 autopsies. The arterial 
tension is usually low in phthisis and the capillary resistance lessened so 



TUBERCULOSIS. 



311 



that the pulse is often full and soft even in the later stages of the disease. 
The capillary pulse is not infrequently met with, and pulsation of the 
veins in the back of the hand is occasionally to be seen. 

(b) Blood Glandular System. — The early anaemia has already been noted. 
It is often more apparent than real, a chloro-anaemia, and the blood-count 
rarely sinks below two millions per cubic millimetre. 

The blood-plates are, as a rule, enormously increased and are seen in the 
withdrawn blood as the so-called Schultze's granule masses. Without any 
significance, they are of interest chiefly from the fact that every few years 
some tyro announces their discovery as a new diagnostic sign of phthisis. 
The leucocytes are greatly increased, particularly in the later stages. 

(c) G astro-intestinal System. — The tongue is usually furred, but may 
be clean and red. Small aphthous ulcers are sometimes distressing. A 
red line on the gums, a symptom to which at one time much attention was 
paid as a special feature of phthisis, occurs in other cachectic states. Ex- 
tensive tuberculous disease of the pharynx, associated with a similar affec- 
tion of the larynx, may interfere seriously with deglutition and prove a 
very distressing and intractable symptom. 

Of late, special attention has been paid to the gastric symptoms of this 
affection. Tuberculosis of the stomach is rare. Ulceration may occur as an 
accidental complication and multiple catarrhal ulcers are not uncommon. 
Interstitial and parenchymatous changes in the mucosa are common (pos- 
sibly associated with the venous stasis) and lead to atrophy, but these can- 
not always be connoted with the symptoms, and they may be found when 
not expected. On the other hand, when the gastric symptoms have been 
most persistent the mucosa may show very little change. It is impossible 
always to refer the anorexia, nausea, and vomiting of consumption to local 
conditions. The hectic fever and the neurotic influences, upon which 
Immermann lays much stress, must be taken into account, as they play 
an important role. The organ is often dilated, and to muscular insuffi- 
ciency alone may be due some of the cases of dyspepsia. The condition of 
the gastric secretion is not constant, and the reports are discordant. In 
the early stages there may be superacidity; later, a deficiency of acid. 

Anorexia is often a marked symptom at the onset; there may be positive 
loathing of food, and even small quantities cause nausea. Sometimes, with- 
out any nausea or distress after eating, the feeding of the patient is a daily 
battle. When practicable, Debove's forced alimentation is of great benefit 
in such cases. Nausea and vomiting, though occasionally troublesome at 
an early period, are more marked in the later stages. The latter may be 
caused by the severe attacks of coughing. S. H. Habershon refers to four 
different causes the vomiting in phthisis: (1) central, as from tuberculous 
meningitis; (2) pressure on the vagi by caseous glands; (3) stimulation 
from the peripheral branches of the vagus, either pulmonary, pharyngeal, 
or gastric; and (4) mechanical causes. 

Of the intestinal symptoms diarrhoea is the most serious. It may come 
on early, but is more usually a symptom of the later stages, and is associ- 
ated with ulceration, particularly of the large bowel. Extensive ulceration 
of the ileum may exist without any diarrhoea. The associated catarrhal 



312 



SPECIFIC INFECTIOUS DISEASES. 



condition may account in part for it, and in some instances the amyloid de- 
generation of the mucous membrane. 

(d) Nervous System. — (1) Focal lesions due to the development of 
coarse tubercles and areas of tuberculous meningo-encephalitis. Aphasia, 
for instance, may result from the growth of meningeal tubercles in the 
fissure of Sylvius, or even hemiplegia may develop. The solitary tubercles 
are more common in the chronic phthisis of children. (2) Basilar menin- 
gitis is an occasional complication. It may be confined to the brain, though 
more commonly it is a (3) cerebro-spinal meningitis, which may come on 
in persons without well-developed local signs in the chest. Twice have I 
known strong, robust men brought into hospital with signs of cerebro- 
spinal meningitis, in whom the existence of pulmonary disease was not 
discovered until the post-mortem. (4) Peripheral neuritis, which is not 
common, may cause an extensor paralysis of the arm or leg, more com- 
monly the latter, with foot-drop. It is usually a late manifestation. (5) 
Mental symptoms. It was noted, even by the older writers, that consump- 
tives had a peculiarly hopeful temperament, and the spes phtliisica forms 
a curious characteristic of the disease. Patients with extensive cavities, 
high fever, and too weak to move will often make plans for the future and 
confidently expect to recover. 

Apart from tuberculosis of the brain, there is sometimes in chronic 
phthisis a form of insanity not unlike that which develops in the con- 
valescence from acute affections. The whole question of the mutual rela- 
tions of insanity and phthisis is dealt with at length in Mickle's Goulstonian 
lectures. 

(e) A remarkable hypertrophy of the mammary gland may occur in pul- 
monary tuberculosis,* most commonly in males. It may be only on the 
affected side. Two cases came under my notice at the University Hospital, 
Philadelphia, both in young males. It is a chronic interstitial, non-tuber- 
culous mammitis (Allot). 

(/) Genito-urinary System. — The urine presents no special peculiari- 
ties in amount or constituents. Fever, however, has a marked influence 
upon it. Albumin is met with frequently and may be associated with the 
fever, or is the result of definite changes in the kidneys. In the latter case 
it is more abundant and more curd-like. Amyloid disease of the kidneys 
is not uncommon. Its presence is shown by albumin and tube-casts, 
and sometimes by a great increase in the amount of urine. In other 
instances there is dropsy, and the patients have all the characteristic fea- 
tures of chronic Bright's disease. 

Pus in the urine may be due to disease of the bladder or of the pelves 
of the kidneys. In some instances the entire urinary tract is involved. In 
pulmonary phthisis, however, extensive tuberculous disease is rarely found 
in the urinary organs. Bacilli may occasionally be detected in the pus. 
Hematuria is not a very common symptom. It may occur occasionally 
as a result of congestion of the kidneys, and pass off leaving the urine 
albuminous. In other instances it results from disease of the pelvis 



* Allot, Paris Thesis, 1887. 



TUBERCULOSIS. 



313 



or of the bladder, and is associated either with early tuberculosis of the 
mucous membranes or more commonly with ulceration. In any medical 
clinic the routine inspection of the testes for tubercle will save two or three 
mistakes a year. 

(g) Cutaneous System. — The skin is often dry and harsh. Local tuber- 
cles occasionally develop on the hands. There may be pigmentary staining, 
the chloasma phthisicorum, which is more common when the peritonaeum 
is involved. Upon the chest and back the brown stains of pityriasis versi- 
color are very frequent. The hair of the head and beard may become 
dry and lanky. The terminal phalanges, in chronic cases, become clubbed 
and the nails incurvated — the Hippocratic fingers. A remarkable and un- 
usual complication is general emphysema, which may result from ulcera- 
tion of an adherent lung or perforation of the larynx. 

Diagnosis. — When well advanced there is rarely any doubt as to the 
existence of tuberculous phthisis, for the sputum gives positive informa- 
tion, and the physical signs of local disease are well marked. The bacilli 
give an infallible indication of the existence of tuberculosis and may be 
found in the sputum before the physical signs are at all definite. On the 
other hand, it must be remembered that there are cases in which, even 
with tolerably well-defined physical signs, the sputum is extremely scanty 
and many examinations may be required to detect tubercle bacilli. So 
essential is the examination of the sputum in the early diagnosis of phthisis 
that I would earnestly insist upon the more frequent employment of this 
method. There is no excuse now for its omission, since, if the practitioner 
has not command of the necessary technique, there are laboratories in 
many parts of the country at which the examination can be made. Early 
detection is of vital importance, as successful treatment depends upon the 
measures taken before the lungs are extensively involved. 

The presence of elastic fibres in the sputum is an indication of destruc- 
tion of the lung-tissue. In a large proportion of cases it is indicative, too, 
of tuberculous disease. It also may be found early, before the physical 
signs are well marked. Its detection is easy by the above-mentioned method, 
not requiring high powers of the microscope. In cases of early haemoptysis, 
before there is marked constitutional disturbance, or even local signs, it is 
very important to make a thorough examination of the sputum, from 
which mucoid and purulent portions may be picked out for examination. 
With localized and persistent signs in one lung, cough, fever, and loss of 
flesh, the diagnosis is rarely dubious. It is remarkable, however, to what 
an extent the local process may sometimes proceed without disturbance 
of health sufficient to excite the alarm of the physician or friends. There 
are puzzling cases with localized physical signs at one apex, chiefly moist 
rales, rarely any percussion changes, perhaps slight fever, and a glairy 
expectoration containing numerous alveolar cells. I have seen several 
cases of this kind which have been for a time very obscure, and in which 
repeated examinations failed to detect either bacilli or elastic tissue. They 
seem to be instances of local catarrhal trouble in the smaller tubes, some 
of which clear in a few weeks. 



SPECIFIC INFECTIOUS DISEASES. 



3. Fibroid Phthisis. 

In their monograph, on Fibroid Diseases of the Lung (1894) Clark 
Hadley and Chaplin make the following classification: 1. Pure fibroid; 
fibroid phthisis — a condition in which there is no tubercle. 2. Tuberculo- 
fibroid disease — a condition primarily tuberculous, but which has run a 
fibroid course. 3. Fibro-tuberculous disease — a condition primarily fibroid, 
but which has become tuberculous. The tuberculo-fibroid form may come 
on gradually as a sequence of a chronic tuberculous broncho-pneumonia, 
or follow a chronic tuberculous pleurisy. In other instances the process 
supervenes upon an ordinary ulcerative phthisis. The disease becomes 
limited to one apex, the cavity is surrounded by layers of dense fibrous 
tissue, the pleura is thickened, and the lower lobe is gradually invaded by 
the sclerotic change. Ultimately a picture is produced little if at all differ- 
ent from the condition known as cirrhosis of the lungs. It may even be 
difficult to say that the process is tuberculous, but in advanced cases the 
bacilli are usually present in the walls of the cavity at the apex, or old, 
encapsulated caseous areas exist in the lung, or there may be tubercles at 
the apex of the other lung and in the bronchial glands. Dilatation of the 
bronchi is present; the right ventricle, sometimes the entire heart, is hyper- 
trophied. 

The disease is chronic, lasting from ten to twenty or more years, dur- 
ing which time the patient may have fair health. 

The chief symptoms are cough, which is often paroxysmal in character 
and most marked in the morning. The expectoration is purulent, and 
in some instances, when the bronchiectasis is extensive, fetid. There is 
dyspnoea on exertion, but little or no fever. 

The physical signs are very characteristic. The chest is sunken and 
the shoulder lower on the affected side; the heart is often drawn over and 
displaced. If the left lung is involved there may be an unusually large 
area of cardiac pulsation in the third, fourth, and fifth interspaces. Heart- 
murmurs are common. There is dulness over the affected side and defi- 
cient tactile fremitus. At the apex there may be well-marked cavernous 
sounds; at the base, distant bronchial breathing. The condition may per- 
sist indefinitely. In some cases the other lung becomes involved, or the 
patient has repeated attacks of haemoptysis, in one of which he dies. As 
a result of the chronic suppuration, amyloid degeneration of the liver, 
spleen, and intestines may take place; dropsy frequently supervenes from 
failure of the right heart. 

A more detailed account is found under Cirrhosis of the Lung, with 
which this form is clinically identical. 

Concurrent Infections in Pulmonary Tuberculosis.— It has 
long been known that in pulmonary tuberculosis organisms other than the 
specific bacilli are present, particularly Micrococcus lanceolatus, Strepto- 
coccus pyogenes, and Staphylococcus aureus; less frequently Bacillus pyo- 
cyaneus. 

A majority of all cases of pulmonary tuberculosis are combined infec- 
tions; streptococci and pneumococci may be found in the sputa, and the 



TUBERCULOSIS. 



315 



former have been isolated from the blood. Prudden, who has very care- 
fully studied this question, arrives at the following conclusions: The pul- 
monary lesions of tuberculosis are subject to variations depending largely 
on the different modes of distribution of the bacilli, whether by the blood- 
vessels or through the bronchi, and also whether a concurrent infection 
with other organisms has taken place. The pneumonia complicating tuber- 
culosis may be the direct result of the tubercle bacillus or its toxines, or it 
may follow secondary infection with other germs, particularly the Strepto- 
coccus pyogenes, the Micrococcus lanceolatus, and the Staphylococcus 
pyogenes. The frequency of this secondary infection and the relative sig- 
nificance of these germs are not yet fully decided. The introduction of the 
tubercle bacilli into the lungs of a rabbit through the trachea induces the 
various phases of pulmonary tuberculosis, but cavity formation is rare. If, 
on the other hand, into the lungs of a rabbit which are the seat of extensive 
consolidation the Streptococcus pyogenes is introduced, then cavities form 
rapidly, and the anatomical picture is very similar to that of chronic ulcer- 
ative tuberculosis in man. It is very probable that in man, too, the effect 
of contamination with these pus organisms is a very important one in 
hastening necrosis and softening, and also in the chronic cases they doubt- 
less produce in large amounts the toxines which are responsible for many 
of the symptoms of the disease. 

Diseases associated with Pulmonary Tuberculosis.— Lobar 
pneumonia is a not uncommon cause of death. It is met with, most fre- 
quently indeed, as a terminal event in the chronic cases. It may, however, 
occur early, and be difficult to distinguish from an acute caseous pneu- 
monia. The sputa in the latter are rarely rusty, while the fever in the 
former is more continuous and higher, but in many cases it is impossible 
to differentiate between the two conditions. 

Typhoid fever occasionally occurs in persons the subjects of pulmonary 
tuberculosis. In 4 cases of 80 autopsies in typhoid fever tuberculous lesions 
were present. There are cases on record also of acute miliary tuberculosis 
and typhoid fever present in the same subject. There is a widespread 
opinion that typhoid fever predisposes to tuberculosis, and Wilson Fox 
in his treatise on diseases of the lungs gives references to a number of 
cases. In my experience it has been very rare. I have no recollection of 
an instance in which tuberculosis has developed either during convalescence, 
or immediately after recovery, from typhoid fever. 

Erysipelas not infrequently attacks old poitrinaires in hospital wards 
and almshouses. There are instances in which the attack seems to be bene- 
ficial, as the cough lessens and the symptoms ameliorate. It may, however, 
prove fatal. 

The eruptive fevers, particularly measles, frequently precede, but rarely 
develop in the course of pulmonary tuberculosis. In the revaccination of 
a tuberculous subject the vesicles run a normal course. 

Fistula in ano is associated with phthisis in an interesting manner. 
In a majority of such cases it is a tuberculous process. The general affec- 
tion may progress rapidly after an operation. The question is considered 
in tuberculosis of the alimentary canal. 
20 



316 



SPECIFIC INFECTIOUS DISEASES. 



Heart-disease. — I have already referred (page 298) to the occurrence of 
endocarditis in tuberculosis. The antagonism between heart lesions and 
phthisis, upon which Kokitansky laid stress, is not pronounced. Stenosis 
of the pulmonary artery and aneurism of the aorta predispose to tubercu- 
losis pulmonum, probably by reducing the activity of the lesser circula- 
tion. In mitral stenosis pulmonary tuberculosis is not infrequent, in 9 of 
54 cases (Potain). A terminal acute tuberculosis of one or the other of 
the serous membranes is a very common event in all forms of cardio-vaseu- 
lar disease. 

In chronic and arrested phthisis arteriosclerosis and phleoo-sclerosis 
are not uncommon. Ormerod noted 30 cases of chronic renal disease in 
100 post-mortems. 

The association of tuberculosis with chronic arthritis, upon which cer- 
tain writers lay stress, finds its explanation in the lowered resistance of 
these patients, and the greater liability to infection in the institutions in 
which so many of them live. 

Peculiarities of Pulmonary Tuberculosis at the Extremes 
of Life. — (a) Old Age. — It is remarkable how common tuberculosis is in 
the aged, particularly in institutions. McLachlan noted 145 cases in which 
tuberculosis was the cause of death in old persons in Chelsea Hospital. 
All were over sixty years of age. The experience at the Salpetriere is the 
same. Laennec met with a case in a person over ninety-nine years of age. 

At the Philadelphia Hospital, in the bodies of aged persons sent over 
from the almshouse it was extremely common to find either old or recent 
tuberculosis. A patient died under my care at the age of eighty-two with 
extensive peritoneal tuberculosis. Pulmonary tuberculosis in the aged is 
usually latent and runs a slow course. The physical signs are often masked 
by emphysema and by the coexisting chronic bronchitis. The diagnosis 
may depend entirely upon the discovery of the bacilli and elastic tissue. 
Contrary to the opinion which was held some years ago, tuberculosis is by 
no means uncommon with senile emphysema. Some of the cases of tuber- 
culosis in the aged are instances of quiescent disease which may have dated 
from an early period. 

(b) Infants. — The occurrence of acute tuberculosis in children has al- 
ready been mentioned, and also the fact that the disease is occasionally 
congenital. Eecent studies, particularly of French writers, have shown 
that it is a frequent affection in children under two years of age. Leroux 
has analyzed the statistics of the late Prof. Parrot, embracing 219 cases in 
children under three years. Of these there were from one day to three 
months, 23; from three to six months, 35; from six to twelve months, 
53 (a total of 111 under one year); and from one to three years, 108. Pul- 
monary cavities were present in 57 of the cases, and in only 50 was the 
pulmonary lesion the sole manifestation. At the St. Petersburg Foundling 
Asylum, in the ten years ending 1884, there were 416 cases of tuberculosis 
in 16,581 autopsies. The observations of Northrup, at the New York 
Foundling Hospital, are of special interest in connection with the mode 
of infection. Of 125 cases of tuberculosis on the records of this institution, 
in 34 the ravages were extensive, the seat of the primary affection was not 



TUBERCULOSIS. 



317 



clear, and the bronchial glands were large and cheesy. In 20 cases of 
general tuberculosis there were cheesy masses in the bronchial glands and 
in the lungs. In 42 cases of general tuberculosis the only cheesy masses 
were in the bronchial lymph-glands. In 9 cases the tubercles were limited 
to the bronchial nodes and the lungs; the latter containing only discrete 
miliary bodies, while the bronchial glands showed advanced caseation. In 
13 cases there was tuberculosis of the bronchial nodes only. In most of 
these cases the patients died of infectious diseases. These figures are very 
suggestive, and point, as already noted, to infection through the bronchial 
passages as the most common method, even in children. Of 500 autopsies 
in children at the Munich Pathological Institute, in 150 (30 per cent) tuber- 
culosis was present and in over 92 per cent the lungs were involved 
(Miiller). 

Modes of Death in Pulmonary Tuberculosis. — (a) By asthenia, 
a gradual failure of the strength. The end is usually peaceable and quiet, 
occasionally disturbed by paroxysms of cough. Consciousness is often re- 
tained until near the close. 

(b) By asphyxia, as in some cases of acute miliary tuberculosis and in 
acute pneumonic phthisis. In chronic phthisis it is rarely seen, even when 
pneumothorax develops. 

(c) By syncope. This is not common. I have known it to happen once 
or twice in patients who insisted upon going about when in the advanced 
stages of the disease. There may be, but not necessarily, fatty degeneration 
of the heart. A rapidly developing syncope may follow haemorrhage or 
may be due to thrombosis or embolism of the pulmonary artery, or to pneu- 
mothorax. 

(d) From hemorrhage. The fatal bleeding in chronic phthisis is due 
to erosion of a large vessel or rupture of an aneurism in a pulmonary 
cavity, most commonly the latter. Of 26 cases analyzed by S. West, in 11 
the fatal haemoptysis was due to aneurism, and of 35 cases collected by 
Percy Kidd, aneurism was present in 30. In a case of Curtin's, at the 
Philadelphia Hospital, the bleeding proved fatal before haemoptysis oc- 
curred, as the eroded vessel opened into a capacious cavity. 

(e) With cerebral symptoms. Coma may be due to meningitis, less often 
to uraemia. Death in convulsions is rare. The haemorrhagic pachymenin- 
gitis which develops in some cases of phthisis occasionally causes loss of 
consciousness, but is rarely a direct cause of death. In one of my cases, 
death resulted from thrombosis of the cerebral sinuses with symptoms of 
meningitis. 

V. TUBEKCTTLOSIS OF THE AlIMENTAKT CANAL. 

(a) Lips. — Tuberculosis of the lip is very rare. It occurs occasionally 
in the form of an ulcer, either alone or more commonly in association with 
laryngeal or pulmonary disease. Two cases are reported and the literature 
is analyzed in VerneuiPs Etudes.* The ulcer is usually very sensitive and 
may be mistaken for a chancre or an epithelioma. The diagnosis may be 



* Tome iii, Fasc. I. 



318 



SPECIFIC INFECTIOUS DISEASES. 



made in cases of doubt by inoculation or the examination of a portion for 
tubercle bacilli. 

(b) Tongue—The disease begins by an aggregation of small granular 
bodies on the edge or dorsum. Ulceration proceeds, leaving an irregular 
sore with a distinct but uneven margin, and a rough, often caseous base. 
The disease extends slowly and may form an ulcer of considerable size. 
I have known it to be mistaken for epithelioma and the tongue to be ex- 
cised. It is rarely met with except when other organs are involved. The 
glands of the angle of the jaw are not enlarged and the sore does not yield 
to iodide of potassium, which are points of distinction between the tuber- 
culous and the syphilitic ulcer. In doubtful cases the inoculation test 
should be made, or a portion excised for microscopical examination. 

(c) The salivary glands belong to that small group of organs of the 
body which seem to possess an immunity against tuberculous infection — 
an immunity, however, which in their case is relative, not absolute; a few 
cases have been reported. 

(d) Tubercles of the hard or soft palate nearly always follow extension 
of the disease from neighboring parts. 

(e) Tuberculosis of the Tonsils. — In 7 of 45 consecutive cases in children 
from three months to fifteen years A. Latham demonstrated, by inoculation, 
the presence of tuberculosis of the tonsils either in organs removed by oper- 
ation or post mortem. The observation is of interest in connection with 
the views of Schlenker, who claims that the majority of the cases of tuber- 
culous cervical glands result from infection with tubercle bacilli which 
gain admission by way of the tonsil. A large number of his cases of tuber- 
culous ' cervical adenitis were definitely of a descending variety and asso- 
ciated with tuberculosis of these glands. The majority also had pulmonary 
tuberculosis, and he regards surface infection of the tonsil by tuberculous 
food and sputum far more common than infection by way of the circula- 
tion. The disease may occur as a superficial ulceration. More commonly 
there is an infiltration of the tonsil with miliary tubercles, which produces 
a greater or less hypertrophy which it is practically impossible to distin- 
guish from an ordinary enlargement of the tonsil without a microscopical 
examination. Caseous foci occasionally develop. 

(f) Pharynx. — In extensive laryngeal tuberculosis an eruption of mili- 
ary granules on the posterior wall of the pharynx is not very uncommon. 
In chronic phthisis an ulcerative pharyngitis, due to extension of the dis- 
ease from the epiglottis and larynx, is one of the most distressing of com- 
plications, rendering deglutition acutely painful. Adenoids of the naso- 
pharynx may be tuberculous, as shown by Lermoyez. Macroscopically, they 
do not differ from the ordinary vegetations found in this situation. 

(g) A few instances occur in the literature of tuberculosis of the 
oesophagus. The condition is a pathological curiosity, except in the slight 
extension from the larynx, which is not infrequent; but in a case in my 
wards described by Flexner the ulcer perforated and caused purulent pleu- 
risy. The condition has been fully considered by Claribel Cone, who has 
described a second case from the Johns Hopkins Hospital (Bulletin, Novem- 
ber, 1897). 



TUBERCULOSIS. 



319 



(h) Stomach. — Many cases are reported which are doubtful. Primary 
disease is unknown. Marfan was able to collect only about a dozen authentic 
cases. Perforation of the stomach occurred six times, thrice by a tuberculous 
gland. In Oppolzer's case an ulcer of the colon perforated the organ. In 
Musser's case there was a large tuberculous ulcer 3 X 1-J inches in extent. 
Three cases have been described from my wards by Alice Hamilton (J. PL 
H. Bulletin, April, 1897). 

(i) Intestines. — The tubercles may be (1) primary in the mucous mem- 
brane, or more commonly (2) secondary to disease of the lungs, or in rare 
cases the affection may (3) pass from the peritonaeum. 

(1) Primary intestinal tuberculosis occurs most frequently in children, 
in whom it may be associated with enlargement and caseation of the mesen- 
teric glands, or with peritonitis. It may be difficult to say at the time of 
the autopsy whether the primary lesion has been intestinal or peritoneal. 
I have already referred to Woodhead's statistics showing the remarkable 
frequency of infection through the bowel. In adults primary intestinal 
tuberculosis is rare, occurring in but 1 instance in 1,000 autopsies upon 
tuberculous adults at the Munich Pathological Institute; but now and then 
cases occur in which the disease sets in with irregular diarrhoea, moderate 
fever, and colicky pains. In a few cases haemorrhage has been the initial 
symptom. Regarded at first as a chronic catarrh, it is not until the emacia- 
tion becomes marked or the signs of disease appear in the lungs that the 
true nature is apparent. Still more deceptive are the cases in which the 
tuberculosis begins in the caecum and there are symptoms of appendicitis — 
tenderness in the right iliac fossa, constipation, or an irregular diarrhoea 
and fever. These signs may gradually disappear, to recur again in a few 
weeks and still further complicate the diagnosis. Fatal haemorrhage has 
occurred in several of my cases. Perforation may occur with the forma- 
tion of a pericaecal abscess, or perforation into the peritonaeum may take 
place, or in very rare instances there is partial healing with great thicken- 
ing of the walls and narrowing of the lumen. 

(2) Secondary involvement of the bowels is very common in chronic 
pulmonary tuberculosis, e. g. ? in 566 of the 1,000 Munich autopsies in tuber- 
culosis just referred to. In only three of these cases were the lungs not in- 
volved. The lesions are chiefly in the ileum, caecum, and colon. The 
affection begins in the solitary and agminated glands or on the surface 
of or within the mucosa. The caseation and necrosis lead to ulceration, 
which may be very extensive and involve the greater portion of the mucosa 
of the large and small bowels. In the ileum the Peyer's patches are chiefly 
involved and the ulcers may be ovoid, but in the jejunum and colon they 
are usually round or transverse to the long axis. The tuberculous ulcer 
lias the following characters: (a) It is irregular, rarely ovoid or in the 
long axis, more frequently girdling the bowel; (b) the edges and base are 
infiltrated, often caseous; (c) the submucosa and muscularis are usually 
involved; and (d) on the serosa may be seen colonies of young tubercles or 
a well-marked tuberculous lymphangitis. Perforation and peritonitis are 
not uncommon events in the secondary ulceration. Stenosis of the bowel 
from cicatrization may occur; the strictures may be multiple. 



320 



SPECIFIC INFECTIOUS DISEASES. 



Localized chronic tuberculosis of the ileo-ccecal region is of great im- 
portance. The caecum frequently presents extensive ulceration of the 
mucous membrane, which not uncommonly extends into the appendix. As 
a consequence of the changes produced a definite tumor-like mass develops 
in the right iliac fossa. This varies in size, is usually elongated in a 
vertical direction, hard, slightly movable, or bound down by adhesions and 
very sensitive to pressure. The tumor simulates more or less closely a 
true neoplasm of this region, particularly carcinoma. The condition is 
characterized by gradual constriction of the lumen of the bowel, periodic 
attacks of severe pain, and alternating diarrhoea and constipation. In a few 
cases extirpation of the caecum has been performed with fairly successful 
results. In a second form of this disease, occurring less frequently than 
the former, there is no definite tumor-mass to be felt, but a general indura- 
tion and thickening in the right iliac fossa similar to the local changes 
produced by a recurring appendicitis. In this variety a fistula discharging 
fecal matter occasionally results. Both forms may be distinguished from 
the diseases they simulate by the finding of tubercle bacilli in the stools 
or in the discharge from the fistula when such exists. 

Tuberculosis of the rectum has a special interest in connection with 
fistula in ano, which, according to Spillman's statistics, occurs in about 
3.5 per cent of cases of pulmonary disease. In many instances the lesion 
has been shown to be tuberculous. It is very rarely primary, but if the 
tissue on removal contains bacilli and is infective the lungs are almost 
invariably found to be involved. It is a common opinion that the pul- 
monary symptoms may develop rapidly after the fistula is cut. This may 
have some basis if the operation consists in laying the tract open, and not 
in a free excision. 

(3) Extension from the peritonaeum may excite tuberculous disease in 
the bowels. The affection may be primary in the peritonaeum or extend 
from the tubes in women or the mesenteric glands in children. The coils 
of intestines become matted together, caseous and suppurating foci de- 
velop between the folds, and perforation may take place between the coils. 

VI. TUBEECULOSIS OF THE LlVEE. 

This organ is very constantly involved in (a) general tuberculosis. The 
miliary granulation may be very small and in acute cases scarcely percepti- 
ble. The liver is pale and often fatty. 

(b) A remarkable condition of the organ is produced by the develop- 
ment of the tubercles in the finer bile-vessels. They may attain a con- 
siderable size and are almost always softened in the centre, resembling 
small abscesses. The contents are always bile-stained. The organ may be 
honeycombed with these tuberculous abscesses. 

(c) Large, coarse caseous masses are occasionally found, sometimes in 
association with perihepatitis or tuberculous peritonitis. They may attain 
the size of an orange or may even be larger. 

(d) Tuberculous cirrhosis. With the eruption of miliary tubercles there 
may be slight increase in the connective tissue, which is overshadowed by 



TUBERCULOSIS. 



321 



the fatty change. In all the chronic forms of tubercle in this organ there 
may be fibrous overgrowth. Hanot, who has described several varieties, 
states that the condition may be primary. Practically it is very rare, except 
in connection with chronic tuberculous peritonitis and perihepatitis, when 
the organ may be much deformed by a sclerosis involving the portal canals. 
In this last group there may be symptoms of ascites; as a rule, tuberculosis 
of the liver has a purely anatomical interest. 

VII. Tuberculosis of the Brain and Cord. 

Tuberculosis of the brain occurs as (a) an acute miliary infection caus- 
ing meningitis and acute hydrocephalus; (&) as a chronic meningo-en- 
cephalitis, usually localized, and containing small nodular tubercles; and 
(c) as the so-called solitary tubercle. Between the last two forms there 
are all gradations, and it is rare to see the meninges uninvolved. The 
acute variety has already been considered. I shall here consider the chronic 
form, which develops slowly and has the clinical characters of a tumor. 

It is most common in the young. Of 148 cases collected by Pribram 
118 were under fifteen years of age. Other organs are usually involved, 
particularly the lungs, the bronchial glands, or the bones. In rare in- 
stances no tubercles are found elsewhere. They occur most frequently in 
the cerebellum; next in the cerebrum and then in the pons. The growths 
are often multiple, in 100 out of 183 cases (Gowers). They range in size 
from a pea to a walnut; larger tumors occasionally occur, and sometimes 
an entire lobe of the cerebellum is affected. On section the tubercle pre- 
sents a grayish-yellow, caseous appearance, usually firm and hard, and en- 
circled by a translucent, softer tissue. The centre of the growth may be 
semi-diffluent. As in other localities the tubercle may calcify. The 
tumors are as a rule attached to the meninges, often to the pia at the 
bottom of a sulcus so that they look imbedded in the brain-substance. 
About the longitudinal fissure there may be an aggregation of the growths, 
with compression of the sinus, and the formation of a thrombus. The 
tuberculous tumor not infrequently excites acute meningitis. In localized 
meningo-encephalitis the pia is thickened, tubercles are adherent to the 
under surface and grow about the arteries. It is often combined with 
cerebral softening from interference with the circulation. Several of the 
most characteristic instances which I have seen were on the meninges 
covering the insula. This form may develop in pulmonary tuberculosis, 
causing hemiplegia or aphasia which may persist for months. 

The symptoms of tuberculous growths in the brain are those of tumor, 
and will be considered in the section on the brain. 

In the spinal cord the same forms are found. The acute tuberculous 
meningitis has been considered and is almost always cerebro-spinal. The 
solitary tubercle of the cord is rare. Herter has reported 3 cases and col- 
lected 24 from the literature. It was secondary in all save one case. The 
symptoms are those of spinal tumor or meningitis. 



322 



SPECIFIC INFECTIOUS DISEASES. 



VIII. TUBEKCTTLOSIS OF THE GrENTTO-URINAKY SYSTEM. 

The studies of the past few years, and particularly the work of sur- 
geons and gynaecologists, have taught us the great importance of tubercu- 
losis of this tract. Any part of the genito-urinary system may be invaded. 
The successive involvement of the organs may be so rapid that unless the 
case has been seen early it may be impossible to state with any degree of 
certainty which has been the primary seat of infection. There may be 
simultaneous involvement of various portions of the tract. In tuberculosis 
of the genito-urinary system one always has to bear in mind the possibility 
of latent disease elsewhere in the body. As Bollinger says, tubercle bacilli 
may gain admission at some part of the respiratory tract without produc- 
ing any lesion at the point of entrance, and finally reach a bronchial gland, 
where they set up a tuberculous process of extremely slow development 
without producing any symptoms. From this point bacilli may enter the 
blood stream and lodge in the epididymis or testicle proper, and produce 
nodules which are readily discovered, owing to the ease with which these 
parts are examined. Such a case might be quite easily mistaken for one 
of primary genital tuberculosis, whereas the true primary tuberculous focus 
is far distant. 

Infection of the genito-urinary tract occurs in various ways: 

1. By Hereditary Transmission. — It has been met with in the foetus. 
The comparative frequency of tuberculosis of the testicle in very young 
children suggests very strongly that the uro-genital organs may be involved 
as a result of direct transmission of the disease from the parents. 

2. By infection from areas of tuberculosis already existing in the patient. 

(a) Infection through the Blood. — In many cases uro-genital tuberculosis 
is found at autopsy associated with disease of some distant organ, particu- 
larly the lungs, and it would appear most probable that in them infection 
has been through the blood-vessels. Jani's observations, which were pub- 
lished by Weigert after the author's death, strongly support this theory. 
In studying sections of the genital organs of patients who died of pul- 
monary tuberculosis, he found tubercle bacilli in 5 out of 8 cases in the 
testicle, and in 4 out of 6 cases in the prostate, without in any instance 
finding microscopical evidences of tubercles in these organs. The bacilli 
lay, in the testis, partly within and partly close beside the cellular and 
granular contents of the seminal tubules, while in the prostate they were 
always situated in the neighborhood of the glandular epithelium. 

(b) Infection from the Peritonaeum. — This source of infection, in both 
men and women, is much more frequent than is commonly supposed. The 
intimate relationship between the peritonaeum and bladder in both subjects, 
and with the vesiculse seminales and vasa deferentia in the male, allows of 
a ready way of invasion of these organs by direct extension of the dis- 
ease. The peritonaeum is a frequent source of genital tuberculosis in the 
female. No doubt many cases of tuberculosis of the Fallopian tubes origi- 
nate from this source. The fact that the fimbriated extremity of the 
tube is often most seriously involved points rather strongly in this direc- 
tion, although the fact might be taken as a point in favor of blood infection, 



TUBERCULOSIS. 



823 



favored by its greater vascularity. Various observations go to show that the 
action of the cilia lining the lumina of the Fallopian tubes tends to at- 
tract particles introduced into the peritoneal cavity. Jani's observation 
is very interesting in this connection, as showing the possibility of tubercle 
bacilli entering the tubes from the peritoneal cavity without there being 
any tuberculous peritonitis. He found typical tubercle bacilli in the lumen, 
in sections of a normal Fallopian tube, in a woman who died of pulmonary 
and intestinal tuberculosis. The explanation advanced was that the bacilli 
made their way through the thin peritoneal coat from one of the intestinal 
ulcers, thus reaching the peritoneal cavity, and thence were attracted into 
the Fallopian tube by the current produced by the action of the cilia lining 
the lumen. The intimate relationship between tuberculous peritonitis and 
tuberculosis of the Fallopian tubes is shown in the fact that the latter are 
affected in from 30 to 40 per cent of the cases. 

(c) Infection from other Organs by Direct Extension. — The occurrence 
of direct extension from the peritonaeum has already been mentioned. In 
tuberculous ulceration of the intestine or rectum adhesions to the bladder 
in the male or to the uterus and vagina in the female may occur, with 
resulting fistulas and a direct extension of the disease. Perirectal tuber- 
culous abscesses may lead to secondary involvement of some portion of the 
genito-urinary tract. It must not be forgotten that tuberculosis of the 
vertebras may be followed by tuberculosis of the kidney as a result of direct 
extension of the disease. 

3. By Infection from Without. — Whether uro-genital tuberculosis may 
occur as a result of the entrance of tubercle bacilli into the urethra or 
vagina is still a disputed question. That bacilli gain admission to these 
passages during coitus with a person the subject of uro-genital tuberculosis, 
or by the use of foul instruments or syringes, seems quite probable. The 
possibility of genital tuberculosis occurring in the female as a result of 
coitus with a male the subject of tuberculosis in some portion of the genito- 
urinary system was first suggested by Cohnheim, who stated, however, that 
it rarely, if ever, occurred. Gartner's experiments have been referred to. 

In a patient with intestinal tuberculosis the tubercle bacilli might acci- 
dentally reach the urethra or vagina from the rectum. 

Uro-genital tuberculosis is commonest between the ages of twenty 
and forty years — that is, during the period of greatest sexual activity. 
Males are affected much more frequently than females, the proportion 
being 3 to 1. This great difference is no doubt partly due to the more 
intimate relationship between the urinary and genital systems in the former 
than in the latter. In the male the urethra forms the common outlet for 
the two systems, while in the female there is a separate outlet for each. 

Once the uro-genital tract has been invaded, the disease is likely to 
spread rapidly, and the method of extension is an important one. Quite 
frequently there is direct extension, as when the bladder is involved sec- 
ondarily to the kidney by passage of the disease along the ureter, or where 
the tuberculous process extends along the vas deferens to the vesieula? 
seminales. No doubt surface inoculation occurs in some instances, and to 
this cause may be attributed a certain percentage of cases of vesical and 



&24 



SPECIFIC INFECTIOUS DISEASES. 



prostatic disease following tuberculosis of the kidney. Although this prob- 
ability is acknowledged, there is an element of doubt as to the possibility 
of the kidney becoming affected secondarily to the bladder or prostate by 
the direct passage of the bacilli up the lumen of one ureter; for in such a 
case we have to suppose that a non-motile bacillus, contrary to the laws 
of gravity, ascends against an almost constant current of urine flowing in 
the opposite direction. The lymphatics may afford a means for the spread- 
ing of the disease, but in a greater number of cases than is generally sup- 
posed it takes place by way of the blood-vessels. Cystoscopic examina- 
tions of the bladder not infrequently show the presence of tubercles beneath 
the mucous membrane before there is any evidence of superficial ulceration 
— a fact suggesting strongly a blood infection. 

The discovery of tubercle bacilli in the urine and the obtaining of 
tuberculous lesions in animals as a result of inoculation with the urinary 
sediment afford us the only positive evidence of genito-urinary tubercu- 
losis. So far there, are no authentic accounts of tubercle bacilli having 
been found in the semen of men with tuberculosis of the testicle or vesiculse 
seminales. Owing to the fact that the smegma bacillus has the same stain- 
ing reaction as the tubercle bacillus, and, morphologically, is practically 
indistinguishable from it, the greatest care must be used in obtaining 
the specimen of urine for examination, to eliminate, if possible, all chances 
of contamination. Thus the urine examined must be a catheterized speci- 
men, and even then one runs the risk of carrying back into the bladder 
on the end of the catheter a few bacilli which may be washed out in the 
stream of urine and be mistaken for tubercle bacilli in the sediment. 

(a) Tuberculosis of the Kidneys (Phthisis renum). — In general tuber- 
culosis the kidneys frequently present scattered miliary tubercles. In pul- 
monary tuberculosis it is common to find a few nodules in the substance 
of the organ, or there may be pyelitis. Primary tuberculosis of the kidneys 
is not very rare. In a majority of the cases the process involves the pelvis 
and the ureter as well, sometimes the bladder and prostate. In only 1 of 
8 cases was the prostate involved. It may be difficult to say in advanced 
cases whether the disease has started in the bladder, prostate, or vesicles, 
and crept up the ureters, or whether it started in the kidneys and pro- 
ceeded downward. In a majority of cases, I believe, the latter is true, and 
the infection is through the blood. One kidney alone may be involved, and 
the disease creeps down the ureter and may only extend a few millimetres 
on the vesical mucosa. A man with aortic insufficiency, who had no 
lesions in the lungs, presented a localized patch in the pelvis of the kidney, 
involving a pyramid, while the ureter, 5 cm. from the bladder and at its 
orifice, was thickened and tuberculous. The prostate showed* an area of 
caseation. The process is most common in the middle period of life, but it 
may occur at the extremes of age. It is more frequent in men than in 
women. In the earliest stage, which may be met with accidentally, the dis- 
ease is seen to begin in the pyramids and calyces. Necrosis and caseation 
proceed rapidly, and the colonies of tubercles start throughout the pyramids 
and extend upon the mucous membrane of the pelvis. As a rule, from the 
outset it is a tuberculous pyo-nephrosis. The disease may be confined to one 



TUBERCULOSIS, 



325 



kidney, or progress more extensively in one than in the other. At autopsy 
both organs are usually found enlarged. One kidney may be completely 
destroyed and converted into a series of cysts containing cheesy substance — 
a form of kidney which the older writers called scrofulous. In the putty- 
like contents of these cysts lime salts may be deposited. In other instances 
the walls of the pelvis are thickened and cheesy, the pyramids eroded, 
and caseous nodules are scattered through the organ, even to the capsule, 
which may be thickened and adherent. The other organ is usually less 
affected, and shows only pyelitis or a superficial necrosis of one or two pyra- 
mids. The ureters are usually thickened and the mucous membrane ulcer- 
ated and caseous. Involvement of the bladder, vesiculse seminales, and 
testes is not uncommon in males. 

The symptoms are those of pyelitis. The urine may be purulent for 
years, and there may be little or no distress. Even before the bladder be- 
comes involved micturition is frequent, and many instances are mistaken 
for cystitis. The condition is for many years compatible with fair health. 
The curability is shown by the accidental discovery of the so-called scrofu- 
lous kidney, converted into cysts containing a putty-like substance. In 
cases in which the disease becomes advanced and both organs are affected, 
constitutional symptoms are more marked. There is irregular fever, with 
chills, and loss of weight and strength. General tuberculosis is common. 
In only one of my cases were the lungs uninvolved. In a case at the 
Montreal General Hospital a cyst perforated and caused fatal peritonitis. 

Physical examination may detect special tenderness on one side, or the 
kidney may be palpable in front on deep pressure; but tuberculous pyelo- 
nephritis seldom causes a large tumor. Occasionally the pelvis be- 
comes enormously distended; but this is rare in comparison with its 
frequency in calculous pyelitis. The urine presents changes similar to 
those of ordinary calculous pyelitis — pus-cells, epithelium, and occasionally 
definite caseous masses. Albumin is, of course, present. Tubercle bacilli 
may be demonstrated by the ordinary methods. Tube-casts are not often 
seen. 

To distinguish the condition from calculous pyelitis is often difficult. 
Haemorrhage may be present in both, though not nearly so frequently in 
the tuberculous disease. The diagnosis rests on three points: (1) The de- 
tection of some focus of tuberculosis, as in the testes; (2) the presence of 
tubercle bacilli in the sediment; and (3) the use of tuberculin. In woman 
the kidney involved is now easily determined by catheterizing the ureters 
after the plan of my colleague Kelly. 

The incidence of renal implication in uro-genital tuberculosis may be 
gathered from Orth's Gottingen material, analyzed by Oppenheim. Of 60 
cases there were 34 in which the kidneys were involved. 

Tuberculosis of the suprarenal capsules will be considered under Ad- 
dison's Disease. 

(b) Tuberculosis of the Ureter and Bladder. — This rarely occurs as 
a primary affection, but is nearly always secondary to involvement of other 
parts, particularly the pelvis of the kidney. In the case of uro-genital 
tuberculosis, above mentioned, in a patient who died of heart-disease, the 



826 



SPECIFIC INFECTIOUS DISEASES. 



ureter, just where it enters the bladder, showed a fresh patch of tuber- 
culosis. 

Protracted cystitis, which has come on without apparent cause, is 
always suggestive of tuberculosis. The renal regions, the testes, and the 
prostate should be examined with care. It may follow a pyelo-nephritis, 
or be associated with primary disease of the prostate or vesiculse seminales. 
Primary tuberculosis of the posterior wall of the bladder may simulate 
stone. 

(c) Tuberculosis of the Prostate and Vesiculae Seminales. — The pros- 
tate is frequently involved in tuberculosis of the uro-genital tract. In 
Krzyincki's cases, of 15 males the prostate was involved in 14 and the 
vesiculse seminales in 11. In Orth's cases the prostate was involved in 18 
of the 37 cases in males. These parts are much more frequently involved 
than ordinary post-mortem statistics indicate. Per rectum the prostatic 
lobes are felt to be occupied by hard nodules varying in size from a pea to 
a bean. There is great irritability of the bladder, and agonizing pain in 
catheterization. An extremely rare lesion is primary urethral tuberculosis, 
which may simulate stricture. 

(d) Tuberculosis of the Testes. — This somewhat common affection 
may be primary, or, more frequently, is secondary to tuberculous disease 
elsewhere. Many cases occur before the second year, and it is stated to 
have been met with in the foetus. In infants it is serious and usually asso- 
ciated with tuberculous disease in other parts. In 9 cases reported by 
Hutinel and Deschamps, in every one there was a general affection. In 
20 cases reported by Jullien, 6 were under one year, and 6 between one 
and two years old. In 5 of the cases both testicles were affected. Koplik 
holds that most of the instances of this kind are congenital, in Baumgarten's 
sense. In the adult the tubercles begin within the substance of the gland, 
but in children the tunica albuginea is first affected. The tubercle does 
not always undergo caseation, but it may present a number of embryonic 
cells, not unlike a sarcoma. 

Tubercle of the testes is most likely to be confounded with syphilis. 
In the latter the body of the organ is most often affected, there is less 
pain, and the outlines of the growth are more nodular and irregular. In 
obscure peritoneal disease the detection of tubercle in a testis has not in- 
frequently led to a correct diagnosis. The association of the two condi- 
tions is not uncommon. The lesion in the testis may heal completely, or 
the disease may become generalized. General infection has followed opera- 
tion. Too much stress cannot be laid on the importance of a routine 
examination of the testes in hospital patients. 

(e) Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus— The 
Fallopian tubes are by far the most frequent seat of genital tuberculosis. 
The disease may be primary and produce a most characteristic form of 
salpingitis, in which the tubes are enlarged, the walls thickened and infil- 
trated, and the contents cheesy. Adhesion takes place between the fimbriae 
and the ovaries, or the uterus may be invaded. The condition is usually 
bilateral. It may occur in young children. Although, as a rule, very evi- 
dent to the naked eye, there are specimens resembling ordinary salpingitis, 



TUBERCULOSIS. 



327 



which show on microscopical examination numerous miliary tubercles 
(Welch and Williams). Tuberculous salpingitis may cause serious local 
disease with abscess formation, and it may be the starting-point of peri- 
tonitis. 

Tuberculosis of the ovary is always secondary. There may be an erup- 
tion of tubercles over the surface in an extensive involvement of the stroma 
with abscess formation. 

Tuberculosis of the uterus is very rare. Only three examples have come 
under my observation, all in connection with pulmonary phthisis. It may 
be primary. The mucosa of the fundus is thickened and caseous, and tuber- 
cles may be seen in the muscular tissue. Occasionally the process extends 
to the vagina. 

IX. Tuberculosis of the Mammary Gland. 

Mandry (Bruns's Beitrage, viii) has collected 40 cases, 1 of which was 
in a male. The disease is most common between the fortieth and sixtieth 
years. The breast is frequently fistulous, unevenly indurated, and the 
nipple is retracted. The fistulas and ulcers present a characteristic tuber- 
culous aspect. There is also a cold tuberculous abscess of the breast. The 
axillary glands are affected in about two thirds of the cases. The disease 
runs a chronic course of months or years. The diagnosis can be made by 
the general appearance of the fistula* and ulcers, and by the existence of 
tubercle bacilli. The prognosis is not bad, if total eradication of the dis- 
ease be possible. 

In 1836 Bedor described an hypertrophy of the breast in the subjects 
of pulmonary tuberculosis. As a rule, if one gland is involved, usually on 
the side of the affected lung, as already mentioned, the condition is one of 
chronic interstitial mammitis, and is not tuberculous. 

X. Tuberculosis of the Circulatory System. 

(a) Myocardium. — Scattered miliary tubercles are sometimes met with 
in the acute disease. Larger caseous tubercles are excessively rare. A. 
Moser states that there are only 46 cases on record. There is also a scle- 
rotic tuberculous myocarditis. 

(b) Endocardium. — In 216 autopsies in cases of chronic phthisis I found 
endocarditis in 12. As a rule, it is a secondary form, the result of a mixed 
infection, so common in pulmonary tuberculosis. A true tuberculous en- 
docarditis does, however, occur, directly dependent upon infection with 
the bacillus of Koch. As a rule, it is a vegetative endocarditis, not to be 
distinguished from that caused by Streptococcus or Staphylococcus. In 
rare cases, however, caseous tubercles develop. 

(c) Arteries. — Primary tuberculosis of the larger blood-vessels is un- 
known. The disease may, however, occur in a large artery and not result 
from external invasion. In a case of chronic tuberculosis Flexner found a 
fresh tuberculous growth in the aorta, which had no connection with cheesy 
masses outside the vessel. 



328 



SPECIFIC INFECTIOUS DISEASES. 



In the lungs and other organs attacked by tuberculosis the arteries are 
involved in an acute infiltration which usually leads to thrombosis, or tuber- 
cles may develop in the walls and proceed to caseation and softening fre- 
quently with a resulting haemorrhage. By extension into vessels, particu- 
larly veins, the bacilli are widely distributed with the production of miliary 
tuberculosis. 

XI. Diagnosis of Tuberculosis. 

The recognition of the disease usually rests upon the macroscopical 
and microscopical appearances of the lesions and the presence of the char- 
acteristic bacilli. Of late an important additional diagnostic agent has 
been introduced in the form of Koch's tuberculin. For some years Tru- 
deau has insisted upon the harmlessness of its use in the diagnosis of ob- 
scure cases. During the past few years it has been employed extensively 
at the. Johns Hopkins Hospital, both on the medical and surgical sides, 
with the most satisfactory results, and, so far as I know, without any harm- 
ful effects. In obscure internal lesions, in joint cases, and in suspected 
tuberculosis of the kidneys the use of the tuberculin gives most valuable 
information. I may mention, for example, an instance of Addison's dis- 
ease in a young, very muscular man without any sign whatever of visceral 
tuberculosis. The reaction (as, indeed, might have been expected) was 
very characteristic. We have used the tuberculin kindly furnished from 
the Saranac Laboratory, which is made on Koch's original plan. In adults 
a milligramme is employed, and if this has no reaction a larger dose of two 
or three milligrammes is employed in two or three days. There is often 
slight local irritation following the injection, and within from ten to twelve 
hours the febrile reaction begins, the temperature rising to from 102° 
to 104°. 

XII. The Prognosis in Tuberculosis. 

Not all persons in whose bodies the bacilli gain a foothold present 
marked signs of tuberculosis. As will be stated in the next section, local 
disease is found in a considerable number of all cadavers. Infection does 
not necessarily mean the establishment of a progressive and fatal disease. 
In my autopsies, excluding cases dead of pulmonary phthisis, 7.5 per cent 
presented tuberculous lesions of the lungs — a low percentage in compari- 
son with other records, as I carefully excluded the simple fibroid pucker- 
ing at the apex, and the solitary cheesy nodules, unless surrounded by colo- 
nies of tubercles. 

In many cases a natural or spontaneous cure is effected, for the condi- 
tions favorable to the development of the disease are not present — in other 
words, the tissue-soil is unsuitable. Apart from this group, a majority of 
which probably do not show any sign of disease, there may be spontaneous 
arrest after the symptoms have become decided. Many years ago Flint 
called attention to the self-limitation and intrinsic tendency to recovery 
in well-marked pulmonary tuberculosis. Of his 670 cases, 44 recovered, 
and in 31 the disease was arrested, spontaneously in 23 of the first group 



TUBERCULOSIS. 



329 



and in 15 of the second. This natural tendency to cure is still more strik- 
ingly shown in lymphatic and bone tuberculosis. 

The following may be considered favorable circumstances in the prog- 
nosis of pulmonary tuberculosis: A good family history, previous good 
health, a strong digestion, a suitable environment, and an insidious onset, 
without high fever, and without extensive pneumonic consolidation. Cases 
beginning with pleurisy seem to run a more protracted and more favorable 
course. Eepeated attacks of haemoptysis are unfavorable. When well estab- 
lished the course of tuberculosis in any organ is marked by intervals of 
weeks or months in which the fever lessens, the symptoms subside, and 
there is improvement in the general health. 

In pulmonary cases the duration is extremely variable. Laennec placed 
the average duration at two years, and for the majority of cases this is 
perhaps a correct estimate. Pollock's large statistics of over 3,500 cases 
shows a mean duration of the disease of over two years and a half. Wil- 
liams's analysis of 1,000 cases in private practice shows a much more pro- 
tracted course, as the average duration was over seven years. 

Under the subject of prognosis comes the question of the marriage of 
persons who have had tuberculosis, or in whose family the disease prevails. 
The following brief statements may be made with reference to it: 

(a) Subjects with healed lymphatic or bone tuberculosis marry with 
personal impunity and may beget healthy children. It is undeniable, how- 
ever, that in such families, scrofula, caries of the bone, arthritis, cerebral 
and pulmonary tuberculosis are more common. Which is it, " heredite 
de graine ou heredite de terrain," as the French have it, the seed or the 
soil, or both? We cannot yet say. The risks, however, are such as may 
properly be taken. 

(b) The question of marriage of a person who has arrested or cured 
lung tuberculosis is more difficult to decide. In a male, the personal risk 
is not so great; and when the health and strength are good, the external 
environment favorable, and the family history not extremely bad the ex- 
periment — for it is such — is often successful, and many healthy and happy 
families are begotten under these circumstances. In women the question 
is complicated with that of child-bearing, which increases the risks enor- 
mously. With a localized lesion, absence of hereditary taint, good phy- 
sique, and favorable environment, marriage might be permitted. When 
tuberculosis has existed, however, in a girl whose family history is bad, 
whose chest expansion is slight, and whose physique is below the standard, 
the physician should, if possible, place his veto upon marriage. 

(c) With existing disease, fever, bacilli, etc., marriage should be pro- 
hibited. Pregnancy usually hastens the process, though it may be held 
in abeyance. After parturition the disease advances rapidly. There is 
much truth, indeed, in the remark of Dubois: " If a woman threatened with 
phthisis marries, she may bear the first accouchement well; a second, with 
difficulty; a third, never." Conception may occur in an advanced stage 
of the disease. 



330 



SPECIFIC INFECTIOUS DISEASES. 



XIII. Pkophylaxis in Tubeeculosis. 

(a) General. — The sputa of phthisical patients should be carefully col- 
lected and destroyed. Patients should be urged not to spit about care- 
lessly, but always to use a spit-cup and never to swallow the sputa. Sev- 
eral forms of portable flasks have been devised and are now on sale. The 
destruction of the sputa of consumptives should be a routine measure in 
both hospital and private practice. Thorough boiling or putting it into 
the fire is sufficient. In hospitals it is well to have printed directions as 
to the care of the sputa and also printed cards for out-patients, giving the 
most important rules. It should be explained to the patient that the only 
risk, practically, is from this source. The chances of infection are greatest 
in young children. The nursing and care of consumptives involve very 
slight risks indeed if proper precautions are taken. The patient should 
occupy a single bed. 

A second important general prophylactic measure relates to the inspec- 
tion of dairies and slaughter-houses. The possibility of the transmission 
of tuberculosis by infected milk has been fully demonstrated, and in the 
interest of public health the state should take measures to stamp out tuber- 
culosis in cattle. Systematic veterinary inspection of dairies, particularly 
in the large cities, should be made, and full power granted to confiscate and 
kill suspected animals. The abattoirs should be under skilled veterinary 
control, and the carcasses of animals with advanced tuberculosis confis- 
cated. 

Other important preventive measures are the placing of pulmonary tu- 
berculosis on the list of diseases to be reported to the boards of health, the 
institution of civic and state sanitoria in which early cases can be treated, 
and lastly, the establishment of hospitals for the reception of chronic 
cases. 

(b) Individual. — A mother with pulmonary tuberculosis should not 
suckle her child. An infant born of tuberculous parents, or of a family 
in which consumption prevails, should be brought up with the greatest 
care and guarded most particularly against catarrhal affections of all kinds. 
Special attention should be given to the throat and nose, and on the first 
indication of mouth-breathing, or any obstruction of the naso-pharynx, 
a careful examination should be made for adenoid vegetations. The child 
should be clad in flannel and live in the open air as much as possible, avoid- 
ing close rooms. It is a good practice to sponge the throat and chest night 
and morning with cold water. Special attention should be paid to diet 
and to the mode of feeding. The meals should be at regular hours and 
the food plain and substantial. From the outset the child should be en- 
couraged to drink freely of milk. Unfortunately, in these cases there 
seems to be an uncontrollable aversion to fats of all kinds. As the child 
grows older, systematically regulated exercise or a course of pulmonary 
gymnastics may be taken. In the choice of an occupation preference 
should be given to an out-of-door life. Families with a marked predisposi- 
tion to tuberculosis should, if possible, reside in an equable climate. It 
would be best for a young man belonging to such a family to remove to 



TUBERCULOSIS. 



331 



Colorado or Southern California, or to some other suitable climate, before 
trouble begins. 

The trifling ailments of children should be carefully watched. In the 
convalescence from the fevers, which so frequently prove dangerous, the 
greatest caution should be exercised to prevent catching cold. Cod-liver 
oil, the syrup of the iodide of iron, and arsenic may be given. As men- 
tioned, care of the throat in these children is very important. Enlarged 
tonsils should be removed. 

XIV. Treatment of Tuberculosis. 

I. The Natural or Spontaneous Cure. — The spontaneous healing of 
local tuberculosis is an every-day affair. Many cases of adenitis and dis- 
ease of the bone or of the joints terminate favorably. The healing of pul- 
monary tuberculosis is shown clinically by the recovery of patients in whose 
sputa elastic tissue and bacilli have been found; anatomically, by the pres- 
ence of lesions in all stages of repair. In the granulation products and 
associated pneumonia a scar-tissue is formed, while the smaller caseous areas 
become impregnated with lime salts. To such conditions alone should 
the term healing be applied. When the fibroid change encapsulates but 
does not involve the entire tuberculous tissue, the tubercle may be termed 
involuted or quiescent, but is not destroyed. When cavities of any size 
have formed, healing, in the proper sense of the term, does not occur. 
I have yet to see a specimen which would indicate that a vomica had cica- 
trized. Cavities may be greatly reduced in size — indeed, an entire series 
of them may be so contracted by sclerosis of the tissue about them that 
an upper lobe, in which this process most frequently occurs, may 'be re- 
duced to a third of its ordinary dimensions. Laennec understood thor- 
oughly this natural process of cure in tuberculosis, and recognized the 
frequency with which old tuberculous lesions occurred in the lungs. He 
described cicatrices completes and cicatrices ftstuleuses, the latter being the 
shrunken cavities communicating with the bronchi; and remarked that, as 
tubercles growing in the glands, which are called scrofula, often heal, why 
should not the same take place in the lungs? 

There is an old German axiom, "Jedermann hat am Ende ein bisclicn 
Tuberculose," a statement partly borne out by the statistics showing the 
proportion of cases in persons dying of all diseases in whom quiescent or 
tuberculous lesions are found in the lungs. We find at the apices the 
following conditions, which have been held to signify healed tuberculous 
processes: (1) Thickening of the pleura, usually at the posterior surface 
of the apex, with subadjacent induration for a distance of a few milli- 
metres. This has, perhaps, no greater significance than the milky patch 
on the pericardium. (2) Puckered cicatrices at the apex, depressing the 
pleura, and on section showing a large pigmented, fibrous scar. The bron- 
chioles in the neighborhood may be dilated, but there are neither tubercles 
nor cheesy masses. This may sometimes, but not always, indicate a healed 
tuberculous lesion. (3) Puckered cicatrices with cheesy or cretaceous 
nodules, and with scattered tubercles in the vicinity. (4) The cicatrices 
21 



332 



SPECIFIC INFECTIOUS DISEASES. 



fistuleuses of Laennec, in which the fibroid puckering has reduced the size 
of one or more cavities which communicate directly with the bronchi. 

In 1,000 autopsies, excluding the 216 cases dead of phthisis, there were 
59 cases (7.5 per cent) which presented undoubted tuberculous lesions in 
the lungs. I excluded the simple fibroid puckering and the solitary cheesy 
nodules, unless, in the latter case, there were colonies of tubercles in the 
vicinity. These 59 cases died of various diseases and at various ages. A 
majority of them were between forty and sixty. My experience tallies 
closely with the larger analysis made by Heitler of the Vienna post-mortem 
records, in which, of 16,562 cases in which the death was not directly caused 
by phthisis, there were 780 instances of obsolete tubercle — a percentage of 
4.7. He excluded, as I have done, the simple fibroid induration. Vari- 
ous observations have been made of late in which the percentage ranges 
from 27 (Bollinger) to 39 (Massini). In 200 autopsies, in which this point 
was specially examined, Harris found 38.8 per cent in which there were 
relics of former active tuberculosis. The statement is made by Bouchard 
that, of the post-mortems at the Paris morgue — generally upon persons 
dying suddenly — the percentage found with some evidence of tuberculous 
lesion, active or obsolete, is as high as 75. Large as these figures appear, 
they are probably very incorrect. If, as has been done in Kibbert's labo- 
ratory, a systematic inspection is made for the purpose, tuberculous lesions 
are found in practically 100 per cent of the bodies of adults! 

II. General Measures. — The cure of tuberculosis is a question of nutri- 
tion; digestion and assimilation control the situation; make a patient grow 
fat and the local disease may be left to take care of itself. There are three 
indications: First, to place the patient in surroundings most favorable for 
the maintenance of a maximum degree of nutrition; second, to take such 
measures as, in a local or general way, influence the tuberculous processes; 
third, to alleviate symptoms. 

Open-air Treatment. — The value of fresh air and out-of-door life 
is well illustrated by an experiment of Trudeau. Inoculated rabbits con- 
fined in a dark, damp place rapidly succumbed, while others, allowed to run 
wild, either recovered or showed slight lesions. It is the same in human 
tuberculosis. A patient confined to the house — particularly in the close, 
overheated, stuffy dwellings of the poor, or treated in a hospital ward — 
is in a position analogous to that of the rabbit confined to a hutch in the 
cellar; whereas a patient living in the fresh air and sunshine for the greater 
part of the day has chances comparable to those of the rabbit running wild. 

The open-air treatment of tuberculosis may be crrried out at home, 
by change of residence to a suitable climate, or in a sanatorium. 

(a) At Home. — In a majority of all cases the patient has to be cared for 
in his own home, and if in the city, under very disadvantageous circum- 
stances. Much, however, may be done even in cities to promote arrest by 
insisting upon plenty of fresh air. It is often impossible to attempt any 
systematic open-air treatment in city life, but there are many cases in which 
it can be done if the physician insists and if he lays down explicit rules. 
The patient's bed should be in the room with most sunshine. While there 
is fever he should he at rest in hed, and for the greater part of each day, 



TUBERCULOSIS. 



333 



unless the weather is blustering and rainy, the windows should be open, 
so that the patient may be exposed freely to the fresh air. Low tempera- 
ture is not a contraindication. If there is a balcony or a suitable yard, on 
the brighter days the patient may be wrapped up and put in a reclining 
chair or on a sofa. The important thing is for the physician to emphasize 
the fact that neither the cough, fever, night sweats, and not even haemop- 
tysis contraindicate a full exposure to the fresh air. In country places 
this can be carried out much more effectively. I always advise to give 
the patient an almanac, that he can tick off the number of hours of sun- 
shine. In the summer he should be out of doors for at least eleven or 
twelve hours, and in winter six or eight hours. At night the room should 
be cool and thoroughly well ventilated. In the early stages of the disease 
with much fever, it may require several months of this rest treatment in 
the open air before the temperature falls to normal. 

(b) Treatment in Sanatoria. — Perhaps the most important advance in 
the treatment of tuberculosis has been in the establishment in favorable 
localities of institutions in which patients are made to live according to 
strict rules. To Brehmer, of Gobersdorf, we owe the successful execution of 
this plan, which has been followed in Germany with most gratifying results. 
In this country the zeal, energy, and scientific devotion of Edward L. 
Trudeau have demonstrated its feasibility, and the Saranac institution 
has become a model of its kind. We need public sanatoria within easy 
access of the large cities, in which cases of early tuberculosis could be 
treated at low rates or at the public cost. Private sanatoria for the well- 
to-do classes are urgently needed. The results at Gobersdorf, Falkenstein, 
and Saranac demonstrate the great importance of system and rigid disci- 
pline in carrying out a successful treatment of tuberculosis. Within the 
past three years much has been done both in the United States and Great 
Britain to promote the sanatorium treatment of tuberculosis. To Dr. 
Knopf, of New York, we are indebted for a persistent advocacy of its value. 
The all-important matter is the establishment near to the large cities of 
public sanatoria for the treatment of cases in the early stages. It is all- 
important that these institutions should be placed in the hands of men in 
whose integrity and scientific ability the profession has full confidence. 
There should be established in the large general hospital special out-patient 
departments for tuberculous patients, from which suitable cases could be 
sent to the civic sanatoria. They could be partly self-supporting, as many 
patients would pay a reasonable sum per month. An attempt is being made 
in Colorado to start an industrial sanatorium on a large scale. 

(c) Climatic Treatment. — This, after all, is only a modification of the 
open-air method. The first question to be decided is whether the patient is 
fit to be sent from home. In many instances it is a positive hardship. A 
patient with well-marked cavities, hectic fever, night sweats, and emacia- 
tion is much better at home, and the physician should not be too much 
influenced by the importunities of the sick man or of his friends. The 
requirements of a suitable climate are a pure atmosphere, an equable tem- 
perature not subject to rapid variations, and a maximum amount of sunshine. 
Given these three factors, and it makes little difference where a patient 



334 



SPECIFIC INFECTIOUS DISEASES. 



goes, so long as he lives an outdoor life. The purity of the atmosphere is 
the first consideration, and it is this requirement that is met so well 
in the mountains and forests. The different climates may be grouped 
into the high altitudes, the dry, warm climates, and the moist, warm 
climates. 

In this country of high altitudes, the Colorado resorts are the most 
important. Of others, those in Arizona and New Mexico have been de- 
veloping rapidly. The rarefaction of the air in high altitudes is of benefit 
in increasing the respiratory movements in pulmonary disease, but brings 
about in time a condition of dilatation of the air-vesicles and a permanent 
increase in the size of the chest which is a marked disadvantage when such 
persons attempt subsequently to reside at the sea-level. The great advan- 
tage of these western resorts is that they are in progressive, prosperous 
countries, in which a man may find means of livelihood and live in com- 
fort. In Europe the chief resorts at high altitudes are at Davos, Les Avants, 
and St. Moritz. Of resorts at a moderate altitude, Asheville and the Adi- 
rondacks are the best known in this country. The Adirondack cure has 
become of late years quite famous. Objections to it are the expense, ex- 
cept in the case of the sanitorium, but for well-to-do people it is by far 
the most satisfactory place. One very decided advantage is that after 
arrest of the disease the patient can return to the sea-level without any 
special risk. The cases most suitable for high altitudes are those in which 
the disease is limited, without much cavity formation, and without much 
emaciation. The thin, irritable patients with chronic tuberculosis and a 
good deal of emphysema are better at the sea-level. The cold winter cli- 
mate seems to be of decided advantage in tuberculosis, and in the Adiron- 
dacks, where the temperature falls sometimes to 20° or even more below 
zero, the patients are able to lead an out-of-door life throughout the entire 
winter. 

Of the moist, warm climates, in this country Florida and the Bermudas, 
in Europe the Madeira Islands, and in Great Britain Torquay and Fal- 
mouth are the best known. 

Of the dry, warm climates, Southern California in this country is the 
most satisfactory. Many of the health resorts in the Southern States, such 
as Aiken, Thomasville, and Summerville, are delightful winter climates 
for tuberculous cases. Egypt, Algiers, and the Eiviera are the most satis- 
factory resorts for patients from Europe. For additional information on 
the subject of climate, particularly in this country, the reader is referred 
to Solly's recent work on the subject. 

Other considerations which should influence the choice of a locality 
are good accommodations and good food. Very much is said concerning 
the choice of locality in the different stages of pulmonary tuberculosis, 
but when the disease is limited to an apex, in a man of fairly good personal 
and family history, the chances are that he may fight a winning battle if 
he lives out of doors in any climate, whether high, dry and cold, or low, 
moist and warm. With bilateral disease and cavity formation there is but 
little hope of permanent cure, and the mild or warm climates are prefer- 
able. 



TUBERCULOSIS. 



335 



III. Measures which, by their Local or General Action, influence the 
Tuberculous Process. — Under this heading we may consider the specific, 
the dietetic, and the general medicinal treatment of tuberculosis. 

(a) Specific Treatment. — The use of Koch's original tuberculin has been 
in great part abandoned. Some observers, as Whittaker, have had good 
success with it. In April, 1897, Koch announced the discovery of new 
tuberculins, the most important of which is the so-called tuberculin E. It 
is still under trial. The verdict so far has been not at all favorable, ex- 
cept in lupus. 

A very large number of antitoxines of various sorts have been intro- 
duced within the past few years. Many of them have been submitted to 
very searching tests in the Saranac Laboratory by Trudeau and Baldwin, 
whose careful work has extended over a period of four years. They state 
briefly that, while one or two of the serums have shown a slight degree of 
antitoxic power, in all the others the tests were negative. In none could 
any germicidal or curative influence be demonstrated. 

(&) Dietetic Treatment. — The outlook in tuberculosis depends much 
upon the digestion. It is rare to see recovery in a case in which there is 
persistent gastric trouble, and the physician should ever bear in mind the 
fact that in this disease the primce vice control the position. The early 
nausea and loss of appetite in many cases of phthisis are serious obstacles. 
Many patients loathe food of all kinds. A change of air or a sea voyage 
may promptly restore the appetite. When either of these is impossible, 
and if, as is almost always the case, fever is present, the patient should be 
placed at rest, kept in the open air nearly all day, and fed at stated inter- 
vals with small quantities either of milk, buttermilk, or koumyss, alternat- 
ing if necessary with meat juice and egg albumin. Some cases which are 
disturbed by eggs and milk do well on koumyss. It may be necessary to 
resort to Debove's method of over-alimentation or forced feeding. The 
stomach is first washed out with cold water, and then, through the tube, 
a mixture is given containing a litre of milk, an egg, and 100 grammes of 
very finely powdered meat. This is given three times a clay. Sometimes 
the patients will take this mixture without the unpleasant necessity of the 
stomach-tube, in which case a smaller amount may be given. Eaw eggs 
are very suitable for the purpose of over-feeding, and may be taken in the 
intervals between the meals. Beginning with one three times a day the 
number may be increased to two, three, or even four at a time. In the 
German sanatoria a very special feature is this overfeeding, even when 
fever is present. 

In many cases the digestion is not at all disturbed and the patient can 
take an ordinary diet. It is remarkable how rapidly the appetite and di- 
gestion improve on the fresh-air treatment, even in cases which have to 
remain in the city. Care should be taken that the medicines do not dis- 
turb the stomach. Not infrequently the sweet syrups used in the cough 
mixtures, cod-liver oil, creasote, and the hypophosphites produce irritation, 
and by interfering with digestion do more harm than good. On the other 
hand, the bitter tonics, with acids, and the various malt preparations are 
often in these cases most satisfactory. The indications for alcohol in tuber- 



336 



SPECIFIC INFECTIOUS DISEASES. 



culosis are enfeebled digestion with fever, a weak keart, -and rapid pulse. 
A routine administration is not advisable, and there is no evidence that its 
persistent use promotes fibroid processes in the tuberculous areas. In the 
advanced stages, particularly when the temperature is low between eight 
and ten in the morning, whisky and milk, or whisky, egg, and milk may 
be given with great advantage. The red wines are also beneficial in mod- 
erate quantities. 

(c) General Medical Treatment. — No medicinal agents have any special 
or peculiar action upon tuberculous processes. The influence which they 
exert is upon the general nutrition, increasing the physiological resistance, 
and rendering the tissues less susceptible to invasion. The following are 
the most important remedies which seem to act in this manner: 

Creasote, which may be administered in capsules, in increasing doses, 
beginning with 1 minim three times a day and, if well borne, increasing 
the dose to 8 or 10 minims. It may also be given in solution with tincture 
of cardamoms and alcohol. It is an old remedy, strongly recommended 
by Addison, and the reports of Jaccoud, Fraentzel, and many others show 
that it has a positive value in the disease. Guaiacol may be given as a sub- 
stitute, either internally or hypodermically. In 101 cases in which it was 
used at my clinic, by Meredith Eeese, the chief action was on the cough 
and expectoration, which were much lessened, but the remedy had no essen- 
tial influence on the progress of the disease. 

Cod-liver Oil. — In glandular and bone tuberculosis, this remedy is un- 
doubtedly beneficial in improving the nutrition. In pulmonary tuber- 
culosis its action is less certain, and it is scarcely worthy of the unbounded 
confidence which it enjoyed for so many years. It should be given in small 
doses, not more than a teaspoonful three times a day after meals. It seems 
to act better in children than in adults. Fever and gastric irritation are 
contra-indications to its use. When it is not well borne, a dessertspoonful 
of rich cream three times a day is an excellent substitute. The clotted or 
Devonshire cream is preferable. 

The Hypophosphites. — These in various forms are useful tonics, but it 
is doubtful if they have any other action. They certainly exercise no spe- 
cific influence upon tubercle. They may be given in the form of the syrup 
of the hypophosphites of calcium, sodium, and potassium of the TJ. S. P. 

Arsenic. — There is no general tonic more satisfactory in cases of tuber- 
culosis of all kinds than Fowler's solution. It may be given in o-minim 
doses three times a day and gradually increased; stopping its use when- 
ever unpleasant symptoms arise, and in any case intermitting it every 
third or four week. 

One or two special methods of dealing with pulmonary tuberculosis 
may here be mentioned. The local treatment, by direct injection into the 
lungs, has been practised since its strong advocacy by Pepper. It has, 
however, not gained the general support of the profession, and is occa- 
sionally followed by serious results. As a rule, it may be practised with 
impunity, and the injections may be made with a long hypodermic needle 
into any portion of the lung which is diseased. Iodine, carbolic acid, 
creasote (3-per-cent solution in almond oil), and iodoform have been used 



TUBERCULOSIS. 



337 



for the purpose. The remarkable results which surgeons have recently 
obtained in the treatment of joint tuberculosis by injections of iodoform 
point to this as a remedy which will probably prove of service when in- 
jected directly into the lungs. 

Treatment by compressed air is in many cases beneficial, and under 
its use the appetite improves, there is gain in weight, and reduction of the 
fever. The air may be saturated with creasote. 

IV. Treatment of Special Symptoms in Pulmonary Tuberculosis— (a) 
The Fever. — There is no more difficult problem in practical therapeutics 
than the treatment of the pyrexia of tuberculosis. The patient should be 
at rest, and in the open air for a definite number of hours daily. Fever does 
not contra-indicate an out-of-door life, but it is well for patients with a 
temperature above 100.5° to be at rest. For the continuous pyrexia or the 
remittent type of the early stages, quinine, small doses of digitalis, and 
the salicylates may be tried; but they are uncertain and rarely reliable. 
Under no circumstances is that priceless remedy, quinine, so much abused 
as in the fever of tuberculosis. In large doses it has a moderate antipyretic 
action, but it is just in these efficient doses that it is so apt to disturb the 
stomach. 

Antipyrin and antifebrin may be used cautiously; but it is better, 
when the fever rises above 103°, to rely upon cold sponging or the tepid 
bath, gradually cooled. When softening has taken place and the fever 
assumes the characteristic septic type, the problem becomes still more diffi- 
cult. As shown by Chart XII (which is not by any means an exceptional 
~one), the pyrexia, at this stage, lasts only for twelve or fifteen hours. As 
a rule it is not more than from eight to ten hours in which the fever is 
high enough to demand antipyretic treatment. Sometimes antifebrin, 
given in 2-grain doses every hour for three or four hours before the rise in 
temperature takes place, either prevents entirely or limits the paroxysm. 
If the temperature begins to rise between two and three in the afternoon, 
the antifebrin may be given at eleven, twelve, one, and, if necessary, at 
two. It answers better in this way than given in the single doses. Careful 
sponging of the extremities for from half an hour to an hour during the 
height of the fever is useful. Quinine is of little benefit in this type of 
fever; the salicylates are of still less use. 

(b) Sweating. — Atropine, in doses of gr. t \ 0 6 \ , and the aromatic sul- 
phuric acid in large doses, are the best remedies. When there are cough 
and nocturnal restlessness, an eighth of a grain of morphia may be given 
with the atropine. Muscarin (tt^v of a 1-per-cent solution), tincture of 
mix vomica (Tflxxx), picrotoxin (gr. -gV) may be tried. The patient should 
use light flannel night-dresses, as the cotton night-shirts, when soaked with 
perspiration, have a very unpleasant cold, clammy feeling. 

(c) The cough is a troublesome, though necessary, feature in pulmonary 
tuberculosis. Unless very worrying and disturbing sleep at night, or so 
severe as to produce vomiting, it is not well to attempt to restrict it. When 
irritative and bronchial in character, inhalations are useful, particularly the 
tincture of benzoic or preparations of tar, creasote, or turpentine. The 
throat should be carefully examined, as some of the most irritable and 



338 



SPECIFIC INFECTIOUS DISEASES. 



distressing forms of cough in phthisis result from laryngeal erosions. The 
distressing nocturnal cough, which begins just as the patient gets into 
bed and is preparing to fall asleep, requires, as a rule, preparations of 
opium. Codeia, in quarter or half grain doses, or the syrupus codeiae (5 j) 
may be given. An excellent combination for the nocturnal cough of 
phthisis is morphia (gr. -§-— g-), dilute hydrocyanic acid (fflij-iij), and syrup 
of wild cherry (3 j). The spirits of chloroform, B. P., or the mistura 
chloroformi, IT. S. P., or Hoffman's anodyne, given in whisky before going 
to sleep, are efficacious. Mild counter-irritation, or the application of a 
hot poultice, will sometimes promptly relieve the cough. The morning 
cough is often much relieved by taking immediately after getting up a 
glass of hot milk or a cup of hot water, to which 15 grains of bicarbonate 
of soda have been added. In the later stages of the disease, when cavities 
have formed, the accumulated secretion must be expectorated and the 
paroxysms of coughing are now most exhausting. The sedatives, such as 
morphia and hydrocyanic acid, should be given cautiously. The aromatic 
spirit of ammonia in full doses helps to allay the paroxysm. When the 
expectoration is profuse, creasote internally, or inhalations of turpentine 
and iodine, or oil of eucalyptus, are useful. For the troublesome dysphagia 
a strong solution of cocaine (gr. x) with boric acid (gr. v.) in glycerine and 
water ( § j) may be used locally. 

(d) For the diarrhoea large doses of bismuth, combined with Dover 
powder, and small starch enemata, with or without opium, may be given. 
The acetate of lead and opium pill often acts promptly, and the acid diar- 
rhoea mixture, dilute acetic acid (ttix-xv), morphia (gr. -J), and acetate of 
lead (gr. j-ij), may be tried. 

(e) The treatment of the haemoptysis will be considered in the section 
on haemorrhage from the lungs. Dyspnoea is rarely a prominent symptom 
except in the advanced stages, when it may be very troublesome and dis- 
tressing. Ammonia and morphia, cautiously administered, may be used. 

If the pleuritic pains are severe, the side may be strapped, or painted 
with tincture of iodine. The dyspeptic symptoms require careful treat- 
ment, as the outlook in individual cases depends much upon the condition 
of the stomach. Small doses of calomel and soda often allay the distress- 
ing nausea of the early stage. 

XXXV. LEPROSY. 

Definition. — A chronic infectious disease caused by Bacillus lepra, 
characterized by the presence of tubercular nodules in the skin and mucous 
membranes (tubercular leprosy) or by changes in the nerves (anaesthetic 
leprosy). At first these forms may be separate, but ultimately both are 
combined, and in the characteristic tubercular form there are disturbances 
6f sensation. 

History. — The disease appears to have prevailed in Egypt even so 
far back as three or four thousand years before Christ. The Hebrew writers 
make many references to it, but, as is evident from the description in Leviti- 
cus, many different forms of skin diseases were embraced under the term 



LEPROSY. 



339 



leprosy. Both in India and in China the affection was also known many 
centuries before the Christian era. The old Greek and Eoman physicians 
were perfectly familiar with its manifestations. As evidence of a pre- 
Columbian existence of leprosy in America, Ashmead refers to the old 
pieces of Peruvian pottery representing deformities suggestive of this dis- 
ease. Throughout the middle ages leprosy prevailed extensively in Europe, 
and the number of leper asylums has been estimated at at least 20,000. 
During the sixteenth century it gradually declined. 

The prize essays of the National Leprosy Committee, the Transactions 
of the Berlin Leprosy Conference, and the new journal, Lepra Bibliotheca 
Internationalis (1900), will be found invaluable to young men going to 
India, China, or the Philippines. 

Geographical Distribution. — In Europe leprosy prevails in Ice- 
land, Norway and Sweden, parts of Eussia, particularly about Dorpat, Riga, 
and the Caucasus, and in certain provinces of Spain and Portugal. In 
Great Britain the cases are now all imported. 

In the United States there are three important foci: Louisiana, in which 
the disease has been known since 1785, and has of late increased. The 
statement that it was introduced by the Acadians does not seem to me very 
likely, since the records of its existence in Nova Scotia and New Bruns- 
wick do not date back to that period. Dr. Dyer reports that on January 
12, 1898, he knew of 124 positive living cases, including 25 in the Leper 
Home in Iberville Parish. He adds that it is justifiable to estimate the 
number of lepers in the State of Louisiana as between 300 and 500. In 
California, whither the disease has been imported by the Chinese, cases are 
not very infrequent. I am informed by D. W. Montgomery that there 
are (March 20, 1901) 21 cases in the Twenty-sixth Street Hospital, San 
Francisco. Of these, only 2 are Americans, 10 are Chinese. One white 
only is known to have contracted the disease in San Francisco (Montgom- 
ery). In Minnesota with the Norwegian colonists about 170 lepers are 
known to have settled. The disease has steadily decreased. Bracken, in a 
recent study (December, 1900), states that there are 37 lepers in the North- 
west, 17 of whom are in Minnesota. There is not a single native-born leper 
in the region. A Leprosy Commission has been appointed, but they have 
not yet finally reported on the number of cases. 

The few cases seen in the large cities of the Atlantic coast are imported. 

In the Dominion of Canada there are foci of leprosy in two or three 
counties of New Brunswick, settled by French Canadians, and in Cape 
Breton, Nova Scotia. The disease appears to have been imported from 
Normandy about the end of the last century. The number of cases has 
gradually lessened. Dr. A. C. Smith, the physician in charge of the laza- 
retto, at Tracadie, New Brunswick, reports under date of January 17, 1898, 
that there are 24 lepers at present under his care — 18 males and 6 females. 
Of these, 3 are immigrant Icelanders from Manitoba; 1 is a negro from the 
West India Islands. Dr. Smith states that segregation is gradually stamp- 
ing out the disease in New Brunswick. The cases have dwindled from about 
40 to half that number. In Cape Breton it has almost disappeared. A few 
cases are met with among the Icelandic settlers in Manitoba, and with the 
Chinese the affection has been introduced into British Columbia. Dr. Han- 



340 



SPECIFIC INFECTIOUS DISEASES. 



nington, of Victoria, writes, January 20, 1898, that there are 8 cases known 
in this province. They are segregated on Darcy Island. 

Leprosy is endemic in the West India Islands. It also occurs in Mexico 
and throughout the Southern States. In the Sandwich Islands it spread 
rapidly after 1860, and strenuous attempts have been made to stamp it out 
by segregating all lepers on the island of Molokai. In 1894 there were 1,152 
lepers in the settlement. 

In British India, according to the Leprosy Commission, there are 
100,000 lepers. This is probably a low estimate. In China leprosy prevails 
extensively. In South Africa, it has increased rapidly. In Australia, 
New Zealand, and the Australasian islands it also prevails, chiefly among 
the Chinese. The essays of Ashburton Thompson and James Cantlie deal 
fully with leprosy in China, Australia, and the Pacific islands. 

Etiology. — Bacillus lepras, discovered by Hansen, of Bergen, in 1871, 
is universally recognized as the cause of the disease. It has many points 
of resemblance to the tubercle bacillus, but can be readily differentiated. 
It is cultivated with extreme difficulty, and, in fact, there is some doubt 
as to whether it is capable of growth on artificial media. 

Modes of Infection. — (a) Inoculation. — While it is highly probable that 
leprosy may be contracted by accidental inoculation, the experimental evi- 
dence is as yet inconclusive. With one possible exception negative results 
have followed the attempts to reproduce the disease in man. The Ha- 
waiian convict under sentence of death, who was inoculated on September 
30, 1884, by Arning, four weeks later had rheumatoid pains and gradual 
painful swelling of the ulnar and median nerves. The neuritis gradually 
subsided, but there developed a small lepra tubercle at the site of the inocu- 
lation. In 1887 the disease was quite manifest, and the man died of it six 
years after inoculation. The case is not regarded as conclusive, as he 
had leprous relatives and lived in a leprous country. 

(b) Heredity. — For years it was thought that the disease was transmitted 
from parent to child, but the general opinion, as expressed in the recent 
Leprosy Congress in Berlin, was decidedly against this view. Of course, 
the possibility of its transmission cannot be denied, and in this respect 
leprosy and tuberculosis occupy very much the same position, though men 
with very wide experience have never seen a new-born leper. The young- 
est cases are rarely under three or four years of age. 

(c) By Contagion. — The bacilli are given off from the open sores; they 
are found in the saliva and expectoration in the cases with leprous lesions 
in the mouth and throat, and occur in very large numbers in the nasal 
secretion. Sticker found in 153 lepers, subjects of both forms of the dis- 
ease, bacilli in the nasal secretion in 128, and herein, he thinks, lies the chief 
source of danger. Schaffer was able to collect lepra bacilli on clean slides 
placed on tables and floors near to lepers whom he had caused to read 
aloud. The bacilli have also been isolated from the urine and the milk of 
patients. It seems probable that they may enter the body in many ways 
through the mucous membranes and through the skin. Sticker believes 
that the initial lesion is in an ulcer above the cartilaginous part of the nasal 
septum. One of the most striking examples of the contagiousness of 



LEPROSY. 



341 



leprosy is the following: " In I860, a girl who had hitherto lived at Holst- 
fershof, where no leprosy existed, married and went to live at Tarwast with 
her mother-in-law, who was a leper. She remained healthy, but her three 
children (1, 2, 3) became leprous, as also her younger sister (4), who came 
on a visit to Tarwast and slept with the children. The younger sister de- 
veloped leprosy after returning to Holstfershof. At the latter place a 
man (5), fifty-two years old, who married one of the ' younger sister's ' 
children, acquired leprosy; also a relative (6), thirty-six years old, a tailor 
by occupation, who frequented the house, and his wife (7), who came from 
a place where no leprosy existed. The two men last mentioned are at 
present (1897) inmates of the leper asylum at Dorpat." There is certain 
evidence to show that the disease may be spread through infected clothing, 
and the high percentage of washerwomen among lepers is also suggestive. 

Conditions influencing Infection. — The disease attacks persons of all 
ages. We do not yet understand all the conditions necessary. Evidently 
the closest and most intimate contact is essential. The doctors, nurses, 
and Sisters of Charity who care for the patients are very rarely attacked. 
In the lazaretto at Tracadie not one of the Sisters who for more than forty 
years have so faithfully nursed the lepers has contracted the disease. Father 
Damian, in the Sandwich Islands, and Father Boglioli, in New Orleans, 
both fell victims in the discharge of their priestly duties. There has long 
been an idea that possibly the disease may be associated with some special 
kind of food, and Jonathan Hutchinson believes that a fish diet is the 
tertium quid, which either renders the patient susceptible or with which 
the poison may be taken. 

Morbid Anatomy. — The leprosy tubercles consist of granuloma- 
tous tissue made up of cells of various sizes in a connective-tissue matrix. 
The bacilli in extraordinary numbers lie partly between and partly in the 
cells. The process gradually involves the skin, giving rise to tuberous out- 
growths with intervening areas of ulceration or cicatrization, which in the 
face may gradually produce the so-called fades leontina. The mucous 
membranes, particularly the conjunctiva, the cornea, and the larynx may 
gradually be involved. In many cases deep ulcers form which result in 
extensive loss of substance or loss of fingers or toes, the so-called lepra 
mutilans. In anaesthetic leprosy there is a peripheral neuritis due to the 
development of the bacilli in the nerve-fibres. Indeed, this involvement 
of the nerves plays a primary part in the etiology of many of the impor- 
tant features, particularly the trophic changes in the skin and the disturb- 
ances of sensation. 

Clinical Forms.— (a) Tubercular Leprosy.— Prior to the appear- 
ance of the nodules there are areas of cutaneous erythema which may be 
sharply defined and often hyperaesthetic. This is sometimes known as 
macular leprosy. The affected spots in time become pigmented. In some 
instances this superficial change continues without the development of 
nodules, the areas become anaesthetic, the pigment gradually disappears, 
and the skin gets perfectly white — the lepra alba. Among the patients 
at Tracadie it was particularly interesting to see three or four in this early 
stage presenting on the face and forearms a patchy erythema with slight 



342 



SPECIFIC INFECTIOUS DISEASES. 



swelling of the skin. The diagnosis of the condition is perfectly clear, 
though it may be a long time before any other than sensory changes de- 
velop. The eyelashes and eyebrows and the hairs on the face fall out. The 
mucous membranes finally become involved, particularly of the mouth, 
throat, and larynx; the voice becomes harsh and finally aphonic. Death 
results not infrequently from the laryngeal complications and aspiration 
pneumonia. The conjunctivas are frequently attacked, and the sight is lost 
by a leprous keratitis. 

(b) Anaesthetic Leprosy. — This remarkable form has, in characteristic 
cases, no external resemblance whatever to the other variety. It usually 
begins with pains in the limbs and areas of hyperesthesia or of numbness. 
Very early there may be trophic changes, seen in the formation of small 
bullae (Hillis). Maculae appear upon the trunk and extremities, and after 
persisting for a variable time gradually disappear, leaving areas of anaes- 
thesia, but the loss of sensation may come on independently of the out- 
break of maculae. The nerve-trunks, where superficial, may be felt to be 
large and nodular. The trophic disturbances are usually marked. Pem- 
phigus-like bullae develop in the affected areas, which break and leave 
ulcers which may be very destructive. The fingers and toes are liable to 
contractures and to necrosis, so that in chronic cases the phalanges are 
lost. The course of anaesthetic leprosy is extraordinarily chronic and may 
persist for years without leading to much deformity. One of the most 
prominent clergymen on this continent had anaesthetic leprosy for more 
than thirty years, which did not seriously interfere with his usefulness, and 
not in the slightest with his career. 

Diagnosis. — Even in the early stage the dusky erythematous maculae 
with hyperesthesia or areas of anaesthesia are very characteristic. In an 
advanced grade neither the tubercular nor anaesthetic forms could possibly 
be mistaken for any other affection. In a doubtful case the microscopical 
examination of an excised nodule is decisive. 

Treatment. — There are no specific remedies in the disease. The 
gurjun and chaulmoogra oils have been recommended, the former in doses 
of from 5 to 10 minims, the latter in 2-drachm doses. Calmette's anti- 
venene, 20 to 30 c. c, subcutaneously, has been followed by remarkable re- 
sults. Dyer writes (March 3, 1901) that of 10 cases treated with anti- 
venene, 4 are to all appearances cured, 2 have improved. Segregation 
should be compulsory in all cases except where the friends can show that 
they have ample provision in their own home for the complete isolation 
and proper care of the patient. 

XXXVI. INFECTIOUS DISEASES OF DOUBTFUL NATURE. 

(1) FEBRICULA— EPHEMERAL FEVER. 

Definition. — Fever of slight duration, probably depending upon a 

variety of causes. 

A febrile paroxysm lasting for twenty-four hours and disappearing com- 
pletely is spoken of as ephemeral fever. If it persists for three, four, or 
more days without local affection it is referred to as febricula. 



INFECTIOUS DISEASES OF DOUBTFUL NATURE. 



343 



The cases may be divided into several groups: 

(a) Those which represent mild or abortive types of the infectious 
diseases. It is not very unusual, during an epidemic of typhoid, scarlet 
fever, or measles, to see cases with some of the prodromal symptoms and 
slight fever, which persist for two or three days without any distinctive 
features. I have already spoken of these in connection with the abortive 
type of typhoid fever. Possibly, as Kahler suggests, some of the cases of 
transient fever are due to the rheumatic poison. 

(b) In a larger and perhaps more important group of cases the symp- 
toms develop with dyspepsia. In children indigestion and gastrointes- 
tinal catarrh are often accompanied by fever. Possibly some instances of 
longer duration may be due to the absorption of certain toxic substances. 
Slight fever has been known to follow the eating of decomposing sub- 
stances or the drinking of stale beer; but the gastric juice has remarkable 
antiseptic properties, and the frequency with which persons take from 
choice articles which are "high," shows that poisoning is not likely to 
occur unless there is existing gastro-intestinal disturbance. 

(c) Cases which follow exposure to foul odors or sewer-gas. That a 
febrile paroxysm may follow a prolonged exposure to noxious odors has 
long been recognized. The cases which have been described under this 
heading are of two kinds: an acute severe form with nausea, vomiting, 
colic, and fever, followed perhaps by a condition of collapse or coma; 
secondly, a form of low fever with or without chills. A good deal of doubt 
still exists in the minds of the profession about these cases of so-called 
sewer-gas poisoning. It is a notorious fact that workers in sewers are 
remarkably free from disease, and in many of the cases which have 
been reported the illness may have been only a coincidence. There are 
instances in which persons have been taken ill with vomiting and slight 
fever after exposure to the odor of a very offensive post mortem. 
Whether true or not,, the idea is firmly implanted in the minds of the 
laity that very powerful odors from decomposing matters may produce 
sickness. 

(d) Many cases doubtless depend upon slight unrecognized lesions, such 
as tonsillitis or occasionally an abortive or larval pneumonia. Children 
are much more frequently affected than adults. 

The symptoms set in, as a rule, abruptly, though in some instances 
there may have been preliminary malaise and indisposition. Headache, 
loss of appetite, and furred tongue are present. The urine is scanty and 
high-colored, the fever ranges from 101° to 103°, sometimes in children it 
rises higher. The cheeks may be flushed and the patient has the outward 
manifestations of fever. In children there may be bronchial catarrh with 
slight cough. Herpes on the lips is a common symptom. Occasionally 
in children the cerebral symptoms are marked at the outset, and there may 
be irritation, restlessness, and nocturnal delirium. The fever terminates 
abruptly by crisis from the second to the fourth day; in some instances 
it may continue for a week. 

The diagnosis generally rests upon the absence of local manifestations, 
particularly the characteristic skin rashes of the eruptive fevers, and most 



SPECIFIC INFECTIOUS DISEASES. 



important of all the rapid disappearance of the pyrexia. The cases most 
readily recognized are those with acute gastro-intestinal disturbance. 

The treatment is that of mild pyrexia — rest in bed, a laxative, and a 
fever mixture containing nitrate of potassium and sweet spirits of nitre. 

(2) WEIL'S DISEASE. 

Acute Febrile Icterus. — In 1886 Weil described an acute infectious dis- 
ease, characterized by fever and jaundice. Much discussion has taken place 
concerning the true nature of this affection, but it has not been definitely 
determined whether it is a specific disease or only a jaundice which may 
be due to various causes. The majority of the cases have occurred during 
the summer months. The cases have occurred in groups in different cities. 
A few cases have been reported in this country (Lanphear). Males are 
most frequently affected. Many of the cases have been in butchers. The 
age of the patients has been from twenty-five to forty. 

The disease sets in abruptly, usually without prodromes and often 
with a chill. There are headache, pains in the back, and sometimes in- 
tense pains in the legs and muscles, particularly of the cheeks. The fever 
is characterized by marked remissions. Jaundice appears early. The liver 
and spleen are usually swollen; the former may be tender. The jaundice 
may be light, but in many of the cases described it has been of the ob- 
structive form, and the stools have been clay-colored. Gastro-intestinal 
symptoms are rarely present. The fever lasts from ten to fourteen days; 
sometimes there are slight recurrences, but a definite relapse is rare. 

Albumin is usually present in the urine; hematuria has occurred in 
some cases. 

Cerebral symptoms, delirium and coma, may be present. 

In the few post-mortems which have been made nothing distinctive 
has been found. The investigations of Jaeger render it not impossible 
that this epidemic form of jaundice depends upon infection with a proteus 
— Proteus fluorescens. 

(3) MILK-SICKNESS. 

This remarkable disease prevails in certain districts of the United 
States, west of the Alleghany Mountains, and is connected with the affec- 
tion in cattle known as the trembles. It prevailed extensively in the early 
settlements in certain of the Western States and proved very fatal. The 
general opinion is that it is communicated to man only by eating the flesh 
or drinking the milk of diseased animals. The butter and cheese are also 
poisonous. In animals, cattle and the young of horses and sheep are most 
susceptible. It is stated that cows giving milk do not themselves show 
marked symptoms unless driven rapidly, and, according to Graff, the secre- 
tion may be infective when the disease is latent. When a cow is very ill, 
food is refused, the eyes are injected, the animal staggers, the entire mus- 
cular system trembles, and death occurs in convulsions, sometimes with 
great suddenness. Nothing definite is known as to the cause of the dis~ 
ease. It is most frequent in new settlements. 



INFECTIOUS DISEASES OF DOUBTFUL NATURE. 



345 



In man the symptoms are those of a more or less acute intoxication. 
After a few days of uneasiness and distress the patient is seized with pains 
in the stomach, nausea and vomiting, fever and intense thirst. There is 
usually obstinate constipation. The tongue is swollen and tremulous, the 
breath is extremely foul and, according to Graff, is as characteristic of the 
disease as is the odor in small-pox. Cerebral symptoms — restlessness, irri- 
tability, coma, and convulsions — are sometimes marked, and there may 
gradually be produced a typhoid state in which the patient dies. 

The duration of the disease is variable. In the most acute forms death 
occurs within two or three days. It may last for ten days, or even for 
three or four weeks. Graff states that insanity occurred in one case. The 
poisonous nature of the flesh and of the milk has been demonstrated ex- 
perimentally. An ounce of butter or cheese, or four ounces of the beef, 
raw or boiled, given three times a day, will kill a dog within six days. No 
definite pathological lesions are known. Fortunately, the disease has be- 
come rare, and the observation of Drake, Yandell, and others, that it 
gradually disappears with the clearing of the forests and improved 
tillage, has been amply substantiated. It still prevails in parts of North 
Carolina. 

(4) GLANDULAR FEVER. 

Definition. — An infectious disease of children, developing, as a rule, 
without premonitory signs, and characterized by slight redness of the 
throat, high fever, swelling and tenderness of the lymph-glands of the neck, 
particularly those behind the sterno-cleido-mastoid muscles. The fever is 
of short duration, but the enlargement of the glands persists for from 
ten days to three weeks. 

In children acute adenitis of the cervical and other glands with fever 
has been noted by many observers, but Pfeiffer in 1889 called special 
attention to it under the name of Druesenfieber. He described it as an 
infectious disease of young children between the ages of five and eight 
years, characterized by the above-mentioned symptoms. Since Pfeiffer's 
paper a good deal of work has been done in connection with the subject, 
and in this country West and Hamill, and in England Dawson Williams, 
have more particularly emphasized the condition. 

Etiology. — It may occur in epidemic form. West, of Bellaire, Ohio, 
describes an epidemic of 96 cases in children between the ages of seven 
months and thirteen years. Bilateral swelling of the carotid lymph-glands 
was a most marked feature. In three fourths of the cases the post-cervical, 
inguinal, and axillary glands were involved. The mesenteric glands were 
felt in 37 cases, the spleen was enlarged in 57, and the liver in 87 cases. 
Coryza was not present, and there were no bronchial or pulmonary symp- 
toms. Cases occurred between the months of October and June. The 
nature of the infection has not been determined. 

Symptoms. — The onset is sudden and the first complaint is of pain 
on moving the head and neck. There may be nausea and vomiting and 
abdominal pain. The temperature ranges from 101° to 103°. The tonsils 
may be a little red and the lymphatic tissues swollen, but the throat symp- 



346 



SPECIFIC INFECTIOUS DISEASES. 



toms are quite transient and unimportant. On the second or third day 
the enlarged glands appear, and during the course they vary in size from a 
pea to a goose-egg. They are painful to the touch, but there is rarely any 
redness or swelling of the skin, though at times there is some puffiness of 
the subcutaneous tissues of the neck, and there may be a little difficulty in 
swallowing. In some instances there has been discomfort in the chest and 
a paroxysmal cough, indicating involvement of the tracheal and bronchial 
glands. The swelling of the glands persists for from two to three weeks. 
Among the serious features of the disease are the termination of the 
adenitis in suppuration, which seems rare (though Neumann has met with 
it in 13 cases), and hemorrhagic nephritis. Acute otitis media and retro- 
pharyngeal abscess have also been reported. 

The outlook is favorable. West suggests the use of small doses of calo- 
mel during the height of the trouble. 

(5) MOUNTAIN FEVER— MOUNTAIN SICKNESS. 

Several distinct diseases have been described as mountain fever. An 
important group, the mountain ancemia, is associated with the anchylo stoma, 
which has not yet been met with in this country. A second group of cases 
belongs to typhoid fever; and instances of this disease occurring in moun- 
tainous regions in the Western States are referred to as mountain fever. 
The observations of Hoff and Smart, and more recently of Woodruff and of 
Eaymond, show that the disease is typhoid fever. 

Eecently C. E. Woodruff, of the army, has reported a group of 35 cases 
at Fort Custer, which, as he says, would certainly have been described as 
mountain fever, but in which the clinical features and the Widal reaction 
showed there was no question that they were typhoid. Eaymond, too, re- 
cently called attention to the existence of typhoid fever in Wyoming among 
the Indians in the reservation and the soldiers at the post. It would be 
well, I think, for the use of the term mountain fever to be discontinued. 

Mountain sickness comprises the remarkable group of phenomena which 
develop in very high altitudes. The condition has been very accurately de- 
scribed by Mr. Whymper. In the ascent of Chimborazo they were first 
affected at a height of 16,664 feet. The symptoms were severe headache, 
gasping for breath, evidently urgent oesoin de respirer. The throat was 
parched, and there was intense thirst, loss of appetite, and an intense 
malaise. Mr. Whymper's temperature was 100.4°. The symptoms in his 
case lasted for nearly three days. In a less aggravated form such symp- 
toms may present themselves at much lower levels, and in the ascent of the 
railroad at Pike's Peak many persons suffer from distress in breathing. The 
original cases described by General Fremont were of this nature. A very 
full description is given by Allbutt in vol. iii of his System. 

(6) MILIARY FEVER— SWEATING SICKNESS. 

The disease is characterized by fever, profuse sweats, and an eruption 
of miliary vesicles. It prevailed and was very fatal in England in the 
fifteenth and sixteenth centuries, but of late years it has been con- 



INFECTIOUS DISEASES OF DOUBTFUL NATURE. 



347 



fined entirely to certain districts in France (Picardy) and Italy. An epi- 
demic of some extent occurred in France in 1887. Hirsch gives a chrono- 
logical account of 194 epidemics between 1718 and 1879, many of which 
were limited to a single village or to a few localities. Occasionally the dis- 
ease has become widely spread. Slight epidemics have occurred in Ger- 
many and Switzerland. Within the past few years there have been several 
small outbreaks in Austria. They are usually of short duration, lasting only 
for three or four weeks — sometimes not more than seven or eight days. 
As in influenza, a very large number of persons are attacked in rapid suc- 
cession. In the mild cases there is only slight fever, with loss of appetite, 
an erythematous eruption, profuse perspiration, and an outbreak of miliary 
vesicles. The severe cases present the symptoms of intense infection — de- 
lirium, high fever, profound prostration, and haemorrhage. The death- 
rate at the outset of the disease is usually high, and, as is so graphically 
described in the account of some of the epidemics of the middle ages, death 
may occur in a few hours. The most recent and the fullest account of the 
disease is given in NothnagePs Handbuch by Immermann. 

(7) FOOT AND MOUTH DISEASE— EPIDEMIC STOMATITIS— 
APHTHOUS FEVER. 

Foot and mouth disease is an acute infectious disorder met with chiefly 
in cattle, sheep, and pigs, but attacking other domestic animals. It is of 
extraordinary activity, and spreads with " lightning rapidity " over vast 
territories, causing very serious losses. In cattle, after a period of incuba- 
tion of three or five days, the animal gets feverish, the mucous membrane 
of the mouth swells, and little grayish vesicles the size of a hemp seed 
begin to develop on the edges and lower portion of the tongue, on the 
gums, and on the mucous membrane of the lips. They contain at first a 
clear fluid, which becomes turbid, and then they enlarge and gradually 
become converted into superficial ulcers. There is ptyalism, and the ani- 
mals lose flesh rapidly. In the cow the disease is also frequently seen 
about the udder and teats, and the milk becomes yellowish-white in color 
and of a mucoid consistency. 

The transmission to man is by no means uncommon, and of late sev- 
eral important epidemics have been studied in the neighborhood of Berlin. 
Dr. Salmon informs me that in the United States foot and mouth dis- 
ease has very rarely occurred, but in 1870, as well as in 1841, it was 
communicated in a few instances to man. In ZuilPs translation of Fried- 
berger and Frohner's Pathology and Therapeutics of Domestic Animals 
(Philadelphia, 1895) the disease is thus described: " Transmission of 
aphthous fever to man is not rare. The veterinarian has oftener occasion 
to observe it than the physician. The use of milk from aphthous cows 
contaminates children quite frequently and is fatal to them. This may 
also happen through ingestion of butter or cheese made of milk coming 
from aphthous animals, or also directly through wounds of the arms, hands, 
or by intermediary agents. In man the symptoms are: fever, digestive 
troubles, and vesicular eruption upon the lips, the buccal and pharyngeal 



348 



SPECIFIC INFECTIOUS DISEASES. 



mucous membranes (angina). The disease does not seem to be trans- 
missible through the meat of diseased animals. Perhaps the serious affec- 
tions of the skin which were observed to develop in children after vaccina- 
tion (especially in 1883-^84) may have been determined by mistaking the 
mammary eruption of aphthous fever for cow-pox." 

In widespread epidemics there has been sometimes a marked tendency 
to haemorrhages. The disease runs, as a rule, a favorable course, but in 
SiegePs report of a recent epidemic the mortality was 8 per cent. 

Of great biological interest is Loffler's demonstration that the lymph 
from the vesicles of foot-and-mouth disease retains its full virulence after 
nitration through unglazed porcelain, the pores of which are so minute as 
to prevent the passage of the smallest known bacteria. He concludes that 
the micro-organism is beyond the existing powers of microscopic vision. 
Loffler has devised a method of vaccinating animals against this disease. 

When epidemics are prevailing in cattle the milk should be boiled, 
and the proper prophylactic measures taken to isolate both the cattle and 
the individuals who come in contact with them. 



SECTION II. 



DISEASES DUE TO ANIMAL PAEASITES. 



I. PSOROSPERMOSIS. 

Under this term are embraced several affections produced by the spo- 
rozoa. These parasites, belonging to the protozoa, are also known as psoro- 
sperms and gregarinidas. They are extraordinarily abundant in the in- 
vertebrates, and are not uncommon in the higher mammals. The entire 
group of blood parasites, hamiatozoa, which live within the corpuscles, are 
closely related to them. Psorosperms are, as a rule, parasites of the cells 
— Cytozoa. The commonest and most suitable variety for study is the 
Coccidium oviforme of the rabbit, which produces a disease of the liver in 
which the organ is studded throughout with whitish nodules, ranging in 
size from a pin's head to a split pea. On section each nodule is seen to be 
a dilated portion of a bile-duct; the walls are lined with epithelium in the 
interior of which are multitudes of ovoid bodies — the coccidia. Another 
very common form occurs in the muscles of the pig, the so-called Rainey's 
tube, which is an ovoid body within the sarcolemma containing a number 
of small, sickle-shaped, unicellular organisms, the Sarcocystis miescheri. An- 
other species, the 8. hominis, has been described in man. 

These bodies probably play a more important role in human pathology 
than has hitherto been thought. The cases reported may be grouped under 
the following divisions: internal and external. 

(1) Internal Psorospermiasis. — In a majority of the cases of this group 
the psorosperms have been found in the liver, producing a disease similar 
to that which occurs in rabbits. In Guebler's case there were tumors 
which could be felt in the liver during life, and they were determined by 
Leuckart to be due to coccidia. In W. B. Haddon's case the patient was 
admitted to St. Thomas's Hospital with slight fever and drowsiness; he 
gradually became unconscious; death occurred on the fourteenth day of 
observation. Whitish neoplasms were found upon the peritonaeum, omen- 
tum, and on the layers of the pericardium; and a few were found in the 
liver, spleen, and kidneys. A somewhat similar case, though more remark- 
able, as it ran a very acute course, is reported by Silcott. A woman, aged 
fifty-three, admitted to St. Mary's Hospital, was thought to be suffering from 
typhoid fever. She had had a chill six weeks before admission. There were 

349 



350 



DISEASES DUE TO ANIMAL PARASITES. 



fever of an intermittent type, slight diarrhoea, nausea, tenderness over the 
liver and spleen, and a dry tongue; death occurred from heart-failure. The 
liver was enlarged, weighed 83 ounces, and in its substance there were case- 
ous foci, around each of which was a ring of congestion. The spleen 
weighed 16 ounces and contained similar bodies. The ileum presented six 
papule-like elevations. The masses resembled tubercles, but on examina- 
tion coccidia were found. 

The parasites are also found in the kidneys and ureters. Cases of this 
kind have been recorded by Bland Sutton and Paul Eve. In Eve's case 
the symptoms were hematuria and frequent micturition, and death took 
place on the seventeenth day. The nodules throughout the pelvis and 
ureters have been regarded as mucous cysts. In a case reported by Joseph 
Griffiths the tumors in the ureter caused hydronephrosis. 

(2) Cutaneous Psorospermiasis. — The parasitic nature of the keratosis 
follicularis of White, and of Paget's disease of the nipple, which seemed 
to have been established, has been called in question, and the bodies de- 
scribed as psorosperms are believed to be the result of epithelial degenera- 
tion. So, too, in molluscum contagiosum and in epithelioma, the nature 
of the structures which lie in and between the epithelial cells, and which 
have some resemblance to psorosperms, is still unsettled; some claiming 
that they are truly parasitic, others affirming that they are nothing but 
altered protoplasm of the epithelial cells. 

There are several undoubted instances, however, of parasitic sporozoa 
producing extensive disease of the skin. In "Wernicke's case (from Buenos 
Ayres) the lesions were scattered over the face, trunk, and left thigh. The 
sporozoa were found in numbers in the pus of the skin lesions, and also 
in the inguinal glands, which were excised. 

Eixford and Gilchrist describe two cases (Johns Hopkins Hospital Ee- 
ports, vol. i). In the first case, which was regarded as tuberculosis of the 
skin, the lesion remained local for nearly eight years. The lymphatic glands 
then became involved. The affection gradually attacked the nose, cheeks, 
and other parts of the head, the left hand, the leg, and the left testicle. 
For seven or eight years the patient had no constitutional symptoms, but 
after the glands became involved an intermittent fever developed. In the 
later stages he had a cough with purulent expectoration. The autopsy 
revealed what appeared to be tuberculosis of the lungs, adrenals, and testis. 
There were numerous tuberculous-looking nodules in the spleen, on the 
surface of the liver, and the pleurae. In all'of the lesions enormous numbers 
of sporozoa were found, especially in the caseous masses. Successful inocu- 
lations were made into rabbits and dogs. The second case was similar, but 
much more acute. There were thirty skin lesions distributed over the 
body. The patient died within three months after the appearance of the 
initial lesion. In an excised lymph-gland enormous numbers of sporozoa 
were found. The cycle of development was readily followed. These bodies 
differ in all points from those described as protozoa in cancer and in mol- 
luscum contagiosum. 

Two of the most important protozoon diseases — namely, amoebic dys- 
entery and malaria — have been described. 



DISTOMIASIS. 



351 



II. PARASITIC INFUSORIA. 

Several flagellates have been found parasitic in man. Among the most 
common are the Trichomonas vaginalis, which measures 15 to 25 /x in 
length, and has four flagella, which are as long as or longer than the body. 
It is by no means an uncommon parasite in the acid vaginal mucus. 

The Trichomonas or Cercomonas hominis lives in the intestines, and 
is met with in the stools under all sorts of conditions. It is probably not 
pathogenic. I have seen it also in the vomit in a case of chronic gastric 
catarrh. Trichomonads have been met with also in the urine in several 
cases, and may be truly pathogenic. In Dock's * case the parasites were 
associated with a hemorrhagic cystitis without bacteria. 

The Lamblia intestinalis is another intestinal monad, larger than the 
common Trichomonas. Flagellates have also been found in the expec- 
toration in cases of gangrene of the lung and of bronchiectasis, and in 
pleurisy. 

Among the parasitic Ciliata may be mentioned the Balantidium coli, 
which has been found occasionally in the large intestine in forms of dys- 
entery. The parasite is oval in form, 70 to 100 //, long and 50 to 70 broad. 
It is doubtful whether it is pathogenic. 

III. DISTOMIASIS. 

Several forms of trematodes or flukes are parasitic in man, and when 
in numbers may cause serious disease. 

(1) Liver Flukes. — The following species of flukes have been found: 
The Fasciola hepatica, a very common parasite in ruminants, which has a 
length of from 28 to 32 mm. The Distomum lanceolatum, a much smaller 
form, from 8 to 10 mm. in length, which is also very common in sheep and 
cattle. The Distoma ousfci, the largest form, measuring from 4 to 8 cm. 
in length. One or two other less important forms have occasionally been 
met with. The studies of the Japanese physicians have brought to light 
the interesting fact that there is a distoma widely endemic in certain prov- 
inces in that country. The two forms described as Distoma endemicum and 
Distoma perniciosum are identical, and are known now as Distoma sinense. 
According to Baelz, fully 20 per cent of the inhabitants of certain provinces 
are affected. The Distoma felineum, which has been found recently in this 
country by Ward, of Nebraska, in cats, is a common human parasite in 
Siberia. 

The flukes occupy the bile-passages and the upper portion of the small 
intestine. When in large numbers they may cause serious and fatal dis- 
ease of the liver, usually with ascites and jaundice. The liver may be enor- 
mously enlarged; in Kichner's case it weighed 11 pounds. The flukes may 
cause a chronic cholangitis, leading to great thickening or even calcifica- 
tion of the walls of the bile-duct. The ova have been found in the stools. 
Occasionally the distomes are found under the skin. 



* American Journal of the Medical Sciences, January, 1896. 



352 



DISEASES DUE TO ANIMAL PARASITES. 



The endemic fluke disease of Japan is characterized by enlargement of 
the liver, emaciation, diarrhoea, and frequently ascites. 

(2) The Blood Fluke; Schistosoma haematobium (Bilharzia hcematobia). 
— This trematode is found in Egypt, southern Africa, and Arabia, and is 
the cause in these countries of the endemic haematuria. The female is 
about 2 cm. in length, cylindrical, filiform, and about 0.07 mm. in diame- 
ter. The parasite lives in the venous system, particularly in the portal 
vein, and in the veins of the spleen, bladder, kidneys, and mesentery. Ac-, 
cording to Bilharz, at least 50 per cent of the lower classes in Egypt are 
infected with it. It is not yet known how the parasite gains entrance to 
the body. In all probability it is by drinking impure water containing the 
embryos. 

The symptoms are due to changes in the mucous membrane of the 
urinary organs caused by the presence of the ova in the blood-vessels of 
these parts. Hematuria is the first and most constant symptom, leading 
gradually to anaemia. There is generally pain during micturition. The 
blood is not constant in the urine. The ova of the Bilharzia are readily 
seen under a microscope with a low power. They are ovoid in shape, 
translucent, with a small spike at one end. They may be widely distributed 
in the body — in the submucosa of the bowel, in polypoid excrescences in 
the rectum, in the lungs and elsewhere. 

The disease is rarely fatal; a great majority of the cases recover. Chil- 
dren are more commonly attacked than grown persons, and the disease 
often disappears by the time of puberty. 

(3) Bronchial Fluke; Distomum Westermanni; Parasitic Haemoptysis. — 
In parts of China, Japan, and Formosa there is an epidemic disease, de- 
scribed by Einger and Manson, characterized by attacks of cough and 
haemoptysis associated with the presence of a small fluke in the bronchial 
tubes. 

IV. DISEASES CAUSED BY NEMATODES. 

I. ASCARIASIS. 

(a) Ascaris lumbricoides, the most common human parasite, is found 
chiefly in children. The female is from 7 to 12 inches in length, the male 
from 4 to 8 inches. In form it is cylindrical, being pointed at both ends; it 
has a yellowish-brown, sometimes a slightly reddish color. Four longitudinal 
bands can be seen, and it is striated transversely. The ova, which are 
sometimes found in large numbers in the faeces, are small, brownish-red 
in color, elliptical, and have a very thick covering. They measure 0.075 
mm. in length and 0.058 mm. in width. The life history has been demon- 
strated to be " direct " — i. e., without intermediate host. The parasite 
occupies the upper portion of the small intestine. Usually not more than 
one or two are present, but occasionally they occur in enormous numbers. 
The migrations are peculiar. They may pass into the stomach, whence 
they may be ejected by vomiting, or they may crawl up the oesophagus 
and enter the pharynx, from which they may be withdrawn. A child under 
my care in the small-pox department of the General Hospital, during con- 



DISEASES CAUSED BY NEMATODES. 



353 



valescence, withdrew in this way more than thirty round worms within a 
few weeks. In other instances the worm reaches the larynx, and has been 
known to produce fatal asphyxia, or, passing into the trachea, to cause 
gangrene of the lung. They may go through the Eustachian tube and appear 
at the external meatus. The most serious migration is into the bile-duct. 
There is a specimen in the Wistar-Horner Museum of the University of 
Pennsylvania in which not only the common duct, but also the main 
branches throughout the liver, are enormously distended and packed with 
numerous round worms. The bowel may be blocked, or in rare instances an 
ulcer may be perforated. Even the healthy bowel wall may be penetrated 
(Apostolides). 

A peculiarly irritating substance, often evident to the sense of smell in 
handling specimens, is formed by the round worms. Peiper and others 
suggest that the nervous symptoms, sometimes resembling those of menin- 
gitis, are due to this poison. ChaufTard, Marie, and Tauchon have gone still 
further, and report a remarkable condition of fever, intestinal symptoms, 
foul breath, and intermittent diarrhoea in connection with the presence of 
lumbricoides. They call it typho-lumbricosis. The febrile condition may 
continue for a month or more. The symptoms are supposed to be excited 
reflexly, or to be due to the virulence of the ascarides themselves. It does 
not seem to me a very clearly defined condition, and when one considers 
the extraordinary frequency of lumbricoid worms and the remarkable num- 
ber which may be harbored without causing any special trouble, I think we 
require more evidence before we accept the conclusions of these authors. 

The symptoms are not definite. When a few parasites are present they 
may be passed without causing disturbance. In children there are irritative 
symptoms usually attributed to worms, such as restlessness, irritability, 
picking at the nose, grinding of the teeth, twitchings, or convulsions. These 
symptoms may be marked in very nervous children. 

Treatment. — Santonin can be given, mixed with sugar, in doses of 
from one half to one grain for a child and two to three grains for an adult, 
followed by a calomel or a saline purge. The dose may be given for three 
or four days. An unpleasant consequence which sometimes follows the 
administration of this drug is xanthopsia or yellow vision. 

(b) Oxyuris vermicularis (Thread-worm; Pin-worm). — This common 
parasite occupies the rectum and colon. The male measures about 4 mm. 
in length, the female about 10 mm. They produce great irritation and 
itching, particularly at night, symptoms which become intensely aggravated 
by the nocturnal migration of the parasites. Occasionally peri-rectal ab- 
scesses are formed, containing numbers of the worms. 

The patients become extremely restless and irritable, the sleep is often 
disturbed, and there may be loss of appetite and anaemia. Though most 
common in children, the parasite occurs at all ages. 

The worm is readily detected in the faeces. Infection probably takes 
place through the water or possibly through salads, such as lettuce and 
cresses. A person the subject of the worms passes ova in large numbers 
in the faeces, and the possibility of reinfection must be scrupulously 
guarded against. 



354 



DISEASES DUE TO ANIMAL PARASITES. 



The treatment is simple, though occasionally there are instances in 
which all forms of medication are resisted. A case is mentioned of a gen- 
tleman, aged forty, who had suffered from childhood and had failed to 
obtain any benefit from prolonged treatment by many helminthologists. 
I have reported a case of several years' duration. Santonin may be used 
in small doses, and mild purgatives, particularly rhubarb. Large injec- 
tions containing carbolic acid, vinegar, quassia, aloes, or turpentine may 
be employed. In children the use of cold injections of strong salt and 
water is usually efficacious. They should be repeated for at least ten days. 
In giving the injection care should be taken to have the hips well elevated, 
so that the fluid can be retained as long as possible. For the intense itch- 
ing and irritation at night vaseline may be freely used, or belladonna oint- 
ment. 

II. Tkichiniasis. 

The Trichina spiralis in its adult condition lives in the small intes- 
tine. The disease is produced by the embryos, which pass from the intes- 
tines and reach the voluntary muscles, where they finally become encap- 
sulated larvae — muscle trichinae. It is in the migration of the embryos 
(possibly from poisons produced by them) that the group of symptoms 
known as trichinasis is produced. 

Description of the Parasites. — (a) Adult or intestinal form. The female 
measures from 3 to 4 mm.; the male, 1.5 mm., and has two little projections 
from the hinder end. 

(b) The larva or muscle trichina is from 0.6 to 1 mm. in length and lies 
coiled in an ovoid capsule, which is at first translucent, but subsequently 
opaque and infiltrated with lime salts. The worm presents a pointed head 
and a somewhat rounded tail. 

When flesh containing the trichinae is eaten by man or by any ani- 
mal in which the development can take place, the capsules are digested 
and the trichinae set free. They pass into the small intestine, and about 
the third day attain their full growth and become sexually mature. Yir- 
chow's experiments have shown that on the sixth or seventh day the em- 
bryos are fully developed. The young produced by each female trichina 
have been estimated at several hundred. Leuckart thinks that various 
broods are developed in succession, and that as many as a thousand em- 
bryos may be produced by a single worm. The time from the ingestion 
of the flesh containing the muscle trichinae to the development of the 
brood of embryos in the intestines is from seven to nine days. The 
female worm penetrates the intestinal wall and the embryos are probably 
discharged directly into the lymph spaces (Askanazy), thence into the 
venous system, and by the blood stream to the muscles, which constitute 
their seat of election. Dr. J. Y. Graham, of the University of Alabama, 
has recently reviewed the question of the mode of transmission in an ex- 
haustive monograph, and he gives strong arguments in favor of the trans- 
mission through the blood stream. After a preliminary migration in the 
intermuscular connective tissue they penetrate the primitive muscle-fibres, 
and in about two weeks develop into the full-grown muscle form. In this 



DISEASES CAUSED BY NEMATODES. 



355 



process an interstitial myositis is excited and gradually an ovoid capsule 
develops about the parasite. Two, occasionally three or four, worms may 
be seen within a single capsule. This process of encapsulation has been 
estimated to take about six weeks. Within the muscles the parasites do 
not undergo further development. Gradually the capsule becomes thicker, 
and ultimately lime salts are deposited within it. This change may take 
place in man within four or five months. In the hog it may be deferred 
for many years. The calcification renders the cyst visible, and since first 
seen by Tiedemann, in 1822, and Hilton, in 1832, these small, opaque, oat- 
shaped bodies have been familiar objects to demonstrators of normal and 
morbid anatomy. The trichinae may live within the muscles for an indefi- 
nite period. They have been found alive and capable of developing as late 
as twenty or even twenty-five years after their entrance into the system. 
In many instances, however, the worms are completely calcified. The 
trichina has been found or " raised " in twenty-six different species of ani- 
mals (Stiles). Medical literature abounds in references to its presence in 
fish, earthworms, etc., but these parasites belong to other genera. In 
faecal examinations for the parasite it is well to remember that the " cell 
body " of the anterior portion of the intestine is a diagnostic criterion of 
the T. spiralis. It was first found in the hog by the late Joseph Leidy. 
Experimentally, guinea-pigs and rabbits are readily infected by feeding 
them with muscle containing the larval form. Dogs are infected with 
difficulty; cats more readily. Experimentally, animals sometimes die of 
the disease if large numbers of the parasites have been eaten. In the hog 
th'e trichinae, like the cysticerci, cause few if any symptoms. An animal 
the muscles of which are swarming with living trichinae may be well nour- 
ished and healthy-looking. An important point also is the fact that in 
the hog the capsule does not readily become calcified, so that the parasites 
are not visible as in the human muscles. For a long time the trichina was 
looked upon as a pathological curiosity, but in 1860 Zenker discovered in 
a girl in the Dresden Hospital, who had symptoms of typhoid fever, both 
the intestinal and the muscle forms of the trichinae, since which time the 
disease has been thoroughly studied. 

Man is infected by eating the flesh of trichinous hogs. The incidence 
of the disease in swine varies much in different countries. In Germany, 
where a thorough and systematic microscopic examination of all swine 
flesh is made, the proportion of trichinous hogs is about 1 in 1,852. At 
the Berlin abattoir, where the microscopic examination is conducted by a 
staff of over eighty men and women, two portions are taken from the ab- 
dominal muscles, from the diaphragm, and from the intercostal muscles, 
and one piece from the muscles of the larynx and tongue. A special com- 
pressor is used to flatten the fragments of the muscle, and the examination 
is made with a magnifying power of from 70 to 100 diameters. During 
the three years ending in 1885 there were 603 trichinous hogs detected, a 
ratio of 1 to 1,292. Statistics are not available in England. In the United 
States systematic inspection is unknown, and the statistics are by no means 
extensive enough. "Taking all the examinations of American pork thus 
far made, both at home and abroad, and we have a total of 298,782, in which 



356 



DISEASES DUE TO ANIMAL PARASITES. 



trichina? were found 6,280 times, being 2.1 per cent, or 1 to 48 " (Salmon, 
1884). 

In 1883, in conjunction with A. W. Clement, I examined 1,000 hogs 
at the Montreal abattoir, and found only 4 infected. 

Modes of Infection. — The danger of infection depends entirely upon 
the mode of preparation of the flesh. Thorough cooking, so that all parts 
of the meat reach the boMing point, destroys the parasites; but in large 
joints the central portions are often not raised to this temperature. The 
frequency of the disease in different countries depends largely upon the 
habits of the people in the preparation of pork. In North G-ermany, where 
raw ham and wurst are freely eaten, the greatest number of instances have 
occurred. In South Germany, France, and England cases are rare. In 
this country the greatest number of persons attacked have been Germans. 
Salting and smoking the flesh are not always sufficient, and the Havre 
experiments showed that animals are readily infected when fed with por- 
tions of the pickled or the smoked meat as prepared in this country. Carl 
Fraenkel, however,- states that the experiments on this point have been 
negative, and that it is very doubtful if any cases of trichiniasis in Germany 
have been caused by American pork. Germany has yet to show a single 
case of trichiniasis due to pork of unquestioned American origin. 

Frequency of Infection. — H. II. Williams, of Buffalo, made a thorough 
study of the muscle from 505 unselected autopsies, and found 27 cases of 
trichiniasis, 5.3 per cent. The subjects had all died of causes other than 
trichiniasis. This important study shows how widespread is the disease, 
and that in reality we frequently overlook the sporadic form, a mistake 
which is now less often made, owing to T. E. Brown's discovery of the asso- 
ciated eosinophilia. 

The disease often occurs in epidemics, a large number of persons being 
infected from a single source. Among the best known of these, one occurred 
at Hedersleben, in which there were 337 persons affected, and another at 
Emersleben, in which there were 250 persons attacked. The extensive out- 
breaks of this sort have been, with few exceptions, in North Germany, and 
they are a comment on the inefficiency of the inspection. The statistics on 
the subject in this country have been collected for me by Alfred Mann, 
by F. A. Packard, of Philadelphia, and more exhaustively by C. W. Stiles, 
who states that up to 1893 there was a total of 709 cases; since then he 
says, in a letter of February 7, 1898, there have been 40 or 50 cases re- 
ported. He thinks that 900 would cover the total number thus far re- 
ported for this country. According to States, New York heads the list 
with '129 cases; Illinois shows 119; Massachusetts, 115; Iowa, 108. No 
doubt many cases escape detection, and the case is not very uncommon. 
I have had 7 cases within four years in my wards. 

Symptoms. — The ingestion of trichinous flesh is not necessarily fol- 
lowed by the disease. When a limited number are eaten only a few em- 
bryos pass to the muscles and may cause no symptoms. Well-characterized 
cases present a gastro-intestinal period and a period of general infection. 

In the course of a few days after eating the infected meat there are 
signs of gastro-intestinal disturbance — pain in the abdomen, loss of appe- 



DISEASES CAUSED BY NEMATODES. 



357 



tite, vomiting, and sometimes diarrhoea. The preliminary symptoms, how- 
ever, are by no means constant, and in some of the large epidemics cases 
have been observed in which they have been absent. In other instances 
the gastro-intestinal features have been marked from the outset, and the 
attack has resembled cholera nostras. Pain in different parts of the 
body, general debility, and weakness have been noted in some of the 
epidemics. 

The invasion symptoms develop between the seventh and the tenth day, 
sometimes not until the end of the second week. There is fever, except in 
very mild cases. Chills are not common. The thermometer may register 
102° or 104°, and the fever is usually remittent or intermittent. The mi- 
gration of the parasites into the muscles excites a more or less intense myo- 
sitis, which is characterized by pain on pressure and movement, and by 
swelling and tension of the muscles, over which the skin may be cedema- 
tous. The limbs are placed in the positions in which the muscles are in 
least tension. The involvement of the muscles of mastication and of the 
larynx may cause difficulty in chewing and swallowing. In severe cases 
the involvement of the diaphragm and intercostal muscles may lead to 
intense dyspnoea, which sometimes proves fatal. (Edema, a feature of great 
importance, may be early in the face, particularly about the eyes. Later 
it develops in the extremities when the swelling and stiffness of the mus- 
cles are at their height. Profuse sweats, tingling and itching of the skin, 
and in some instances urticaria, have been described. , 

Blood. — A marked leucocytosis, which may reach above 30,000, is pres- 
ent. A special feature is the extraordinary increase in the number of 
eosinophilic cells, which may comprise more than 50 per cent of all the 
leucocytes. There have been in my wards within the past four years 7 
cases in which this eosinophilia was most pronounced. In 4 of the cases 
the diagnosis was actually suggested by the great increase in the eosino- 
phils; in 1 case they reached 68 per cent of the total number of leuco- 
cytes. 

The general nutrition is much disturbed and the patient becomes 
emaciated and often anaemic, particularly in the protracted cases. The 
patellar tendon reflex may be absent. The patients are usually conscious, 
except in cases of very intense infection, in which the delirium, dry tongue, 
and tremor give a picture suggesting typhoid fever. In addition to the 
dyspnoea, present in the severer infections, there may be bronchitis, and in 
the fatal cases pneumonia or pleurisy. In some epidemics polyuria has been 
a common symptom. Albuminuria is frequent. 

The intensity and duration of the symptoms depend entirely upon the 
grade of infection. In the mild cases recovery is complete in from ten to 
fourteen days. In the severe forms convalescence is not established for 
six or eight weeks, and it may be months before the patient recovers the 
muscular strength. One case in the Hedersleben epidemic was weak eight 
years after the attack. 

Of 72 fatal cases in the IToderslebcn epidemic, the greatest mortality 
occurred in the fourth and fifth and sixth weeks; namely, 52 cases. Two 
died in the second week with severe choleraic symptoms. 



358 



DISEASES DUE TO ANIMAL PARASITES. 



The mortality has ranged in different outbreaks from 1 or 2 per cent 
to 30 per cent. In the Hedersleben epidemic 101 persons died. Among 
456 cases reported in this country there were 122 deaths. 

The anatomical changes are chiefly in the voluntary muscles. The 
trichinae enter the primitive muscle bundles, which undergo granular de- 
generation with marked nuclear proliferation. There is a local myositis, 
and gradually about the parasite a cyst wall is formed. These changes, as 
well as the remarkable alterations in the blood, have been described in full 
by Thomas E. Brown.* Cohnheim has described a fatty degeneration of 
the liver and enlargement of the mesenteric glands. At the time of death 
in the fourth or fifth week or later the adult trichinae are still found in the 
intestines. 

The prognosis depends much upon the quantity of infected meat which 
has been eaten and the number of trichinae which mature in the intestines. 
In children the outlook is more favorable. Early diarrhoea and moder- 
ately intense gastro-intestinal symptoms are, as a rule, more favorable than 
constipation. 

Diagnosis. — The disease should always be suspected when a large 
birthday party or Fest among Germans is followed by cases of apparent 
typhoid fever. The parasites may be found in the remnants of the ham 
or sausages used on the occasion. The worms may be discovered in the 
stools. The stools should be spread on a glass plate or black background 
and examined with a low-power lens, when the trichinae are seen as small, 
glistening, silvery threads. In doubtful cases the diagnosis may be made 
by the removal of a small fragment of muscle. A special harpoon has 
been devised for this purpose by means of which a small portion of the 
biceps or of the pectoral muscle may be readily removed. Under cocaine 
anaesthesia an incision may be made and a small fragment removed. The 
disease may be mistaken for acute rheumatism, particularly as the pains 
are so severe on movement, but there is no special swelling of the joints. 
The great increase in the eosinophiles in the blood is, as mentioned above, 
a most suggestive point in diagnosis. The tenderness is in the muscles 
both on pressure and on movement. The intensity of the gastro-intestinal 
symptoms in some cases has led to the diagnosis of cholera. Many of the 
former epidemics were doubtless described as typhoid fever, which the 
severer cases, owing to the prolonged fever, the sweats, the delirium, dry 
tongue, and gastro-intestinal symptoms, somewhat resemble. The pains 
in the muscles, with tension and swelling, oedema, particularly about the 
eyes, and shortness of breath are the most important diagnostic points. 
Under acute myositis reference has already been made to the cases which 
closely resemble trichiniasis. The epidemic in 1879 on board the training 
ship Cornwall presented symptoms similar to those of trichiniasis. One 
patient died. Two months after burial the body was examined, and living 
and dead nematode worms were found which, as Bastian showed, were not 
the trichina, but a rhabditis. They were probably not parasitic, but en- 
tered the body of the cadet after burial. 



* Journal of Experimental Medicine, vol. iii. 



DISEASES CAUSED BY NEMATODES. 



359 



Prophylaxis. — It is not definitely known how swine become dis- 
eased, it lias been thought that they are infected from rats about slaugh- 
ter-houses, but it is just as reasonable to believe that the rats are infected 
by eating portions of the trichinous flesh of swine. The swine should, as 
far as possible, be grain-fed, and not, as is so common, allowed to eat offal. 
The most satisfactory prophylaxis is the complete cooking of pork and 
sausages, and to this custom in England, France, South Germany, and 
particularly in this country, immunity is largely due. 

Treatment. — If it has been discovered within twenty-four or thirty- 
six hours that a large number of persons have eaten infected meat, the 
indications are to thoroughly evacuate the gastro-intestinal canal. Purga- 
tives of rhubarb and senna may be given, or an occasional dose of calomel. 
Glycerin has been recommended in large doses in order that by passing 
into the intestines it may by its hygroscopic properties destroy the worm. 
Male-fern, kamala, santonin, and thymol have all been recommended in 
this stage. Turpentine may be tried in full doses. There is no doubt that 
diarrhoea in the first week or ten days of the infection is distinctly favor- 
able. The indications in the stage of invasion are to relieve the pains, 
to secure sleep, and to support the patient's strength. There are no medi- 
cines which have any influence upon the embryos in their migration 
through the muscles. 

III. Anchylostomiasis. 

The Uncinaria (Dochmius, Strongylus) duodenalis, also known as the 
Sclerostomum or Anchylostomum duodenale, is the only strongyle harmful to 
man. It belongs to the same family as the Sclerostomum equinum, which 
causes the verminous aneurism in the horse. The parasites live in the 
upper portion of the small intestine, chiefly in the jejunum. They are 
easily seen, the male being from 6 to 10 mm. long, and the female from 
10 to 18 mm. The mouth is provided with a series of tooth-like hooks, 
by means of which the parasite attaches itself to the mucous membrane. 
The male has a prominent expansion or bursa at the tail end. The exist- 
ence of the parasite has long been known, but it was not thought to be 
pathogenic until Griesinger demonstrated its association with the Egyp- 
tion chlorosis. It has also been shown to be the cause of the anaemia 
to which miners and brick-makers are subject. Throughout Europe the 
disease has been widely spread by the employment of Italian and Polish 
laborers. In certain Italian provinces it is extremely prevalent and serious. 
It occurs in the Indies, in Brazil, and the West Indies, and has been de- 
scribed in Jamaica (Strachan). Dobson has shown that there is an extraor- 
dinary prevalence of the worm even among healthy coolies in India and 
Assam, amounting to 80 per cent. Allyn has collected 7 cases reported 
from the United States, in several of which the infection probably came 
through association with foreigners, who brought the parasite with them 
to this country. 

Symptoms. — The parasites withdraw blood by suction, and the symp- 
toms result from this slow depletion. That the parasites produce a toxic 
substance has also been suggested. In the early stage there may only be 
gastric or gastro-intestinal disturbance, but if the parasites are present in 



360 



DISEASES DUE TO ANIMAL PARASITES. 



large numbers anaemia is gradually produced and constitutes the charac- 
teristic feature of the disease. The Egyptian chlorosis, brick-maker's anae- 
mia, tunnel anaemia, miner's cachexia, and mountain anaemia are due to 
this cause. The clinical course is variable. In some instances the anaemia 
develops acutely and reaches a high grade within a short time, causing great 
shortness of breath and oedema. There is serious disturbance of nutrition, 
sometimes diarrhoea and colicky pains; but the most pronounced symptom 
is the pallor and the associated phenomena of chronic anaemia, with debility 
and wasting. The lesions of the intestines are those of chronic catarrh, 
and small haemorrhages occur in the mucosa. The worms are found within 
2 metres of the pylorus, often with their heads buried in the mucosa. Dila- 
tation and hypertrophy of the heart have been found in many cases. Sand- 
with states that in Egypt the disease is most common in peasants who work 
in the damp earth, many of whom are earth-eaters. 

The diagnosis is not difficult. The eggs, which are abundant in the 
stools, are oval, about 52 ^ long by 32 //- broad, and possess a thin, trans- 
parent shell. There is no operculum, as in the ovum of the oxyuris, and 
eggs found in the faeces are in various stages of segmentation. The larvae 
develop in moist earth and readily get into the drinking-water, through 
which infection occurs. 

The systematic employment of latrines and the boiling of all water 
used for drinking purposes are the important prophylactic measures. 
Thymol, recommended by Bozzolo, is a specific, and should be given in 
large doses, 2 grammes (in wafers) at 8 a. m. and 2 grammes at 10 a. m. 
(Sandwith). The diet should be milk and soup. Two hours after the 
second dose of thymol a purge of castor oil or magnesia is given. If neces- 
sary, the treatment may be repeated in a week. 

IV. FlLARIASIS. 

Zoologically the Filaria sanguinis hominis is as yet sub judice. Man- 
son's views are as follows: 

Under the general term Filaria sanguinis hominis three species of 
nematodes are included: 

1. Filaria oancrofti, Cobold, 1877. This is the ordinary blood filaria. 
The embryos are found in the peripheral circulation only during sleep or 
at night. The mosquito is the intermediate host. The embryos measure 
270 to 340 /x long by 7 to 11 ^ broad; tail pointed. The adult male meas- 
ures 83 mm. long by 0.407 mm. broad; the tail forms two turns of a spiral. 
The adult female measures 155 mm. long by 0.715 mm. broad; vulva 2.56 
mm. from anterior extremity; eggs 38 fi by 14 ft. This is the species to 
which the haematochyluria and elephantiasis are attributed. 

2. Filaria diurna, Manson, 1891. The larvae agree with the preceding, 
except that Manson indicates the absence of granules in the axis of the 
body. The worms occur in the peripheral circulation only during the 
day, or when the patient stays awake. Manson suspects that the Filaria loa 
represents the adult stage. 

3. Filaria perstans, Manson, 1891. Only the embryos are known. These 



DISEASES CAUSED BY NEMATODES. 



361 



are much smaller than the preceding — 200 //- long, posterior extremity ob- 
tuse, anterior extremity with a sort of retractile rostellum. 

This is the species to which Manson would attribute the sleeping- 
sickness of the negroes. He is also inclined to regard the Filaria perstans 
as the cause of craw-craw, a papillo-pustular skin eruption of the west 
coast of Africa, which is probably the same as Nielly's dermatose parasitaire, 
the parasite of which was called by Blanchard Rhabditis niellyi. Manson 
has shown that in the blood of the aboriginal Indians in British Guiana 
there are two forms of filarial embryos, which differ somewhat from the 
ordinary types. Daniels and Ozzard have shown the ' extraordinary preva- 
lence of these parasites in the aboriginals — fully 58 per cent. Recently 
Daniels has found the mature filarise in two subjects in the upper part of 
the mesentery, near the pancreas and in the subpericardial fat. 

The most important of these is the Filaria bancrofti, which produces 
the hamiatochyluria and the lymph-scrotum. 

The female produces an extraordinary number of embryos, which enter 
the blood current through the lymphatics. Each embryo is within its 
shell, which is elongated, scarcely perceptible, and in no way impedes the 
movements. They are about the ninetieth part of an inch in length and 
the diameter of a red blood-corpuscle in thickness, so that they readily 
pass through the capillaries. They move with the greatest activity, and 
form very striking and readily recognized objects in a blood-drop under 
the microscope. A remarkable feature is the periodicity in the occurrence 
of the embryos in the blood. In the daytime they are almost or entirely 
absent, whereas at night, in typical cases, they are present in large num- 
bers. If, however, as Stephen Mackenzie has shown, the patient, reversing 
his habits, sleeps during the day, the periodicity is reversed. The further 
development of the embryos appears to be associated with the mosquito, 
which at night sucks the blood and in this way frees them from the body. 
After developing a little it was thought that they were set free in the 
water by the death of the host. S. P. James has found them in the tissues 
of the proboscis of the mosquito, and the infection is probably direct, as in 
malaria. The filarise may be present in the body without causing any 
symptoms. In the blood of animals filarial are very common and rarely 
cause inconvenience. It is only when the adult worms or the ova block 
the lymph channels that certain definite symptoms occur. Manson sug- 
gests that it is the ova (prematurely discharged), which are considerably 
shorter and thicker than the full-grown embryos, which block the lymph 
channels and produce the conditions of hamiatochyluria, elephantiasis, and 
lymph-scrotum. 

The parasite is widely distributed, particularly in tropical and sub- 
tropical countries. Guiteras has shown that the disease prevails exten- 
sively in the Southern States, and since his paper appeared contributions 
have been made by Matas, of New Orleans, Mastin, of Mobile, and De Saus- 
sure, of Charleston. 

The effects produced may be described under the following conditions: 
(a) Hamatochyluria. — Without any external manifestations, and in 
many cases without special disturbance of health, the subject from time 



362 DISEASES DUE TO ANIMAL PARASITES. 

to time passes urine of an opaque white, milky appearance, or bloody, or 
a chylous fluid which on settling shows a slightly reddish clot. The urine, 
may be normal in quantity or increased. The condition is usually inter- 
mittent, and the patient may pass normal urine for weeks or months at a 
time. Microscopically, the chylous urine contains minute molecular fat 
granules, usually red blood-corpuscles in various amounts. The embryos 
were first discovered by Demarquay, at Paris (1863), and in the urine by 
Wucherer, at Bahia, in 1866. It is remarkable for how long the condition 
may persist without serious impairment of the health. A patient, sent to 
me by Dawson, of Charleston, has had hsematochyluria intermittently for 
eighteen years. The only inconvenience has been in the passage of the 
blood-clots which collect in the bladder. At times he has also uneasy sensa- 
tions in the lumbar region. The embryos are present in his blood at night 
in large numbers. Chyluria is not always due to the filaria. The non- 
parasitic form of the disease is considered on page 859. 

Opportunities for studying the anatomical condition of these cases 
rarely occur. In the case described by Stephen Mackenzie the renal and 
peritoneal lymph plexuses were enormously enlarged, extending from the 
diaphragm to the pelvis. The thoracic duct above the diaphragm was im- 
pervious. 

(b) Lymph-scrotum and certain forms of elephantiasis are also caused 
by the filaria. In the former the tissues of the scrotum are enormously 
thickened and the distended lymph-vessels may be plainly seen. A clear, 
sometimes a turbid, fluid follows puncture of the skin. The parasites are 
not always to be found. I have examined two typical cases without finding 
filarise in the exuded fluids or in the blood at night. So also the majority 
of cases of elephantiasis which occur in this country are non-parasitic. 
In China it is stated that the parasites occur in all these cases.* 

Treatment. — So far as I know, no drug destroys the embryos in the 
blood. In infected districts the drinking-water should be boiled or filtered. 
In cases of chyluria the patients should use a dry diet and avoid all excess 
of fat. The chyle may disappear quite rapidly from the urine under these 
measures, but it does not necessarily indicate that the case is cured. So 
long as clots and albumin are present the leak in the lymphoid varix is not 
healed, although the fat, not being supplied to the chyle, may not be pres- 
ent. A single tumblerful of milk will at once give ocular proof of the 
patency or otherwise of the rupture in the varix (Manson). 

The surgical treatment of some of these cases is most successful, par- 
ticularly in the removal of the adult filarial from the enlarged lymph-glands, 
especially in the groin. Maitland states that during the past seven years 
25 operations of this kind have been performed without serious symptoms. 

V. Deacontiasis {Guinea-worm Disease). 

The Filaria or Dracunculus medinensis is a widely spread parasite in 
parts of Africa and the East Indies. In the United States instances occa- 



* For full consideration of the subject of congenital occlusion and dilatation of lymph 
channels, see the work on this subject by Samuel C. Busey, New York, 1878. 



DISEASES CAUSED BY NEMATODES. 



363 



sionally occur. Jarvis reports a case in a post chaplain who had lived at 
Fortress Monroe, Va., for thirty years. Van Harlingen's patient, a man 
aged forty-seven, had never lived out of Philadelphia, so that the worm 
must be included among the parasites of this country. A majority of the 
cases reported in American journals have been imported. 

Only the female is known. It develops in the subcutaneous and inter- 
muscular connective tissues and produces vesicles and abscesses. In the 
large majority of the cases the parasite is found in the leg. Of 181 cases, 
in 124 the worm was found in the feet, 33 times in the leg, and 11 times in 
the thigh. It is usually solitary, though there are cases on record in which 
six or more have been present. It is cylindrical in form, about 2 mm. in 
diameter, and from 50 to 80 cm. in length. 

The worm gains entrance to the system through the stomach, not 
through the skin, as was formerly supposed. It is probable that both male 
and female are ingested; but the former dies and is discharged, while the 
latter after impregnation penetrates the intestine and attains its full de- 
velopment in the subcutaneous tissues, where it may remain quiescent for 
a long time and can be felt beneath the skin like a bundle of string. The 
worm contains an enormous number of living embryos, and to enable them 
to escape she travels slowly downward head first, and, as mentioned, usually 
reaches the foot or ankle. The head then penetrates the skin and the epi- 
dermis forms a little vesicle, which ruptures, and a small ulcer is left, at the 
bottom of which the head often protrudes. The distended uterus ruptures 
and the embryos are discharged in a whitish fluid. After getting rid of 
them the worm will spontaneously leave her host. In the water the em- 
bryos develop in the cyclops — a small crustacean — and it seems likely that 
man is infected by drinking the water containing these developed larva?. 

When the worm first appears it should not be disturbed, as after par- 
turition she may leave spontaneously. When the worm begins to come 
out a common procedure is to roll it round a portion of smooth wood and 
in this way prevent the retraction, and each day wind a little more until 
the entire worm is withdrawn. It is stated that special care must be taken 
to prevent tearing of the worm, as disastrous consequences sometimes fol- 
low, probably from the irritation caused by the migration of the embryos. 

The parasite may be excised entire, or killed by injections of bichloride 
of mercury (1 to 1,000). It is stated that the leaves of the plant called 
amarpattee are almost a specific in the disease. Asafcetida in full doses is 
said to kill the worm. 

In East Africa Kolb states that he found in the abdominal cavity of 
a recently killed native Massai several large nematode worms believed to 
be allied to the filaria medinensis. He thinks this parasite is possibly asso- 
ciated with what is known as the Massai disease, characterized by attacks of 
fever lasting some three days, with tenderness of the abdomen and vomit- 
ing. Kolb thinks that in these cases the filaria? which have become en- 
cysted about the liver " as a normal event in their life history burst their 
cysts, the contents escaping into the peritoneal cavity, thereby giving rise 
to the symptoms." The subject is one which requires further investiga- 
tion. 



364 



DISEASES DUE TO ANIMAL PARASITES. 



VI. Other Nematodes. 

(a) Among less important filarian worms parasitic in man the follow- 
ing may be mentioned: Filaria loa, which is a cylindrical worm of about 

3 cm. in length and whose habitat is beneath the conjunctiva. It has 
been found on the West African coast, in Brazil, and in the West Indies. 
Filaria lentis, which has been found in a cataract. Three specimens have 
been found together. Filaria laMalis, which has been found in a pustule 
in the upper lip. Filaria hominis oris, which was described by Leidy, 
from the mouth of a child. Filaria bronchialis, which has been found 
occasionally in the trachea and bronchi. This parasite has been seen in a 
few cases in the bronchioles and in the lungs. There is no evidence that 
it ever produces an extensive verminous bronchitis similar to that which 
I have described in dogs. Filaria immitis — the common Filaria sanguinis 
of the dog — of which Bowlby has described two cases in man. In one case 
with haematuria female worms were found in the portal vein, and the ova 
were present in the thickened bladder wall and in the ureters. 

(b) Trichocephalus dispar (Whip-worm). — This parasite is not infre- 
quently found in the caecum and large intestine of man. It measures from 

4 to 5 cm. in length, the male being somewhat shorter than the female. 
The worm is readily recognized by the remarkable difference between the 
anterior and posterior portions. The former, which forms at least three 
fifths of the body, is extremely thin and hair-like in contrast to the thick 
hinder portion of the body, which in the female is conical and pointed, and 
in the male more obtuse and usually rolled like a spring. The eggs are 
oval, lemon-shaped, 0.05 mm. in length, and each is provided with a button- 
like projection. 

The number of the worms found is variable, as many as a thousand 
having been counted. It is a widely spread parasite. In parts of Europe 
it occurs in from 10 to 30 per cent of all bodies examined, but in this coun- 
try it is not so common. The trichocephalus rarely causes symptoms. 
It has been thought by certain physicians in the East to be the cause of 
beri-beri. Several cases have been reported recently in which profound 
anaemia has occurred in connection with this parasite, usually with diar- 
rhoea. Enormous numbers may be present, as in Rudolphf s case, without 
producing any symptoms. 

The diagnosis is readily made by the examination of the fasces, which 
contain, sometimes in great abundance, the characteristic lemon-shaped, 
hard, dark-brown eggs. 

(c) Dioctophyme gigas (Eustrongylus gigas). — This enormous nematode, 
the male of which measures about a foot in length and the female about 
three feet, occurs in very many animals and has occasionally been met with 
in man. It is usually found in the renal region and may entirely destroy 
the kidney. 

(d) Strongyloides intestinalis. — Under this name are now included the 
small nematode worms found in the fasces and formerly described as 
Anguillula stercoralis, Anguillula intestinalis, and Rlidbdonema intestinale. 
This parasite occurs abundantly in the stools of the endemic diarrhoea of 



DISEASES CAUSED BY CESTODES. 



365 



hot countries, and has been specially described by the French in the diar- 
rhoea of Cochin-China. It has been found in Manila by Strong, and two 
cases have been reported from my clinic by W. S. Thayer. It is stated 
that the worms occupy all parts of the intestines, and have even been 
found in the biliary and pancreatic ducts. It is only when they are in 
very large numbers that they produce severe diarrhoea and anaemia. 

Acanthocephala (Thorn-headed Worms). 

The Gigantorhynchus or E ' chinorhynchus gigas is a common parasite in 
the intestine of the hog and attains *a large size. The larvae develop in 
cockchafer grubs. The American intermediate host is the June bug 
(Stiles). Lambl found a small Ecliinorhynchus in the intestine of a boy. 
Welch's specimen, which was found encysted in the intestine of a soldier 
at Netley, is stated by Cobbold probably not to have been an Ecliinorhyn- 
chus. Recently a case of Ecliinorhynchus moniliformis has been described 
in Italy by Grassi and Calandruccio. 

V. DISEASES CAUSED BY CESTODES 

(Tape-worms ; Hydatid Disease). 

Man harbors the adult parasites in the small intestine, the larval forms 
in the muscles and solid organs. 

I. Intestinal Cestodes; Tape-worms. 

(a) Tcenia solium, or pork tape-worm. This is not a common form in 
this country. It is much more frequent in parts of Europe and Ask. 
When mature it is from 6 to 12 feet in length. The head is small, round, 
not so large as the head of a pin, and provided with four sucking disks and 
a double row of hooklets; hence it is called, in contradistinction to the 
other form in man, the armed tape-worm. To the head succeeds a narrow, 
thread-like neck, then the segments, or proglottides, as they are called. 
The segments possess both male and female generative organs, and about 
every four hundred and fiftieth becomes mature and contains ripe ova. The 
worm attains its full growth in from three to three and a half months, 
after which time the segments are continuously shed and appear in the 
stools. The segments are about 1 cm. in length and from 7 to 8 mm. in 
breadth. Pressed between glass plates the uterus is seen as a median stem 
with about eight to fourteen lateral branches. There are many thousands of 
ova in each ripe segment, and each ovum consists of a firm shell, inside of 
which is a little embryo, provided with six hooklets. The segments are 
continuously passed, and if the ova are to attain further development they 
must be taken into the stomach, either of a pig, or of man himself. The 
egg-shells are digested, the six-hooked embryos become free, and passing 
from the stomach reach various parts of the body (the liver, muscles, brain, 
or eye), where they develop into the larva? or cysticerci. A hog under these 



366 



DISEASES DUE TO ANIMAL PARASITES. 



circumstances is said to be measled, and the cysticerci are spoken of as 
measles or bladder worms. 

The tcenia solium received its name because it was thought to exist as 
a solitary parasite in the bowel, but two or three or even more worms may 
occur. 

(b) Tcenia saginata or mediocanellata — the unarmed or beef tape-worm. 
This is a longer and larger parasite than the Tcenia solium. It is certainly 
the common tape-worm of this country. Of scores of specimens which I 
have examined almost all were of this variety. According to Berenger- 
Ferand it has spread rapidly in western Europe, owing probably to the 
importation of beef and live-stock from the Mediterranean basin. It may 
attain a length of 15 or 20 feet, or more. The head is large in comparison 
with that of the Tcenia solium, and measures over 2 mm. in breadth. It is 
square-shaped and provided with four large sucking disks, but there are no 
hooklets. The ripe segments are from 17 to 18 mm. in length, and from 
8 to 10 mm. in breadth. The uterus consists of a median stem with from 
fifteen to thirty-five lateral branches, which are given off more dichoto- 
mously than in the Tcenia solium. The ova are somewhat larger, and the 
shell is thicker, but the two forms can scarcely be distinguished by their ova. 
The ripe segments are passed as in the tcenia solium, and are ingested by 
cattle, in the flesh or organs of which the eggs develop into the bladder 
worms or cysticerci. 

Of other forms of tape-worm may be mentioned: 

(c) Dipylidium caninum (Tcenia elliptica, Tcenia cucumerina). A small 
parasite very common in the dog and occasionally found in man; the larva? 
develop in. the lice and fleas of the dog. 

(d) Hymenolepsis diminuta (Tcenia flavo- punctata). A small cestode was 
found in the intestine of a child in Boston, and has since been met with in 
one or two cases. It is common in rats. The larvae develop in Lepidoptera 
and in beetles. 

(e) Hymenolepsis nana (Tcenia nana) occurs not infrequently in Italy; 
the Davainea Madagascariensis (Tcenia Mada,gascariensis) is a rare form. 

(f) Tcenia confusa, a new species described by Ward. 

(g) Bothriocephalus lotus. A cestode worm found only in certain dis- 
tricts bordering on the Baltic Sea, in parts of Switzerland, and in Japan. 
So far as I know, it has not been found in this country except in a few 
imported cases. The parasite is large and long, measuring from 25 to 30 
feet or more. Its head is different from that of the taenia, as it possesses 
two lateral grooves or pits and has no hooklets. The larvae develop in the 
peritonaeum and muscles of the pike and other fish, and it has been shown 
experimentally that they grow into the adult worm when eaten by man. 

Symptoms, — These parasites are found at all ages. They are not 
uncommon in children and are occasionally found in sucklings. W. T. 
Plant refers to a number of cases in children under two years, and there is 
one in the literature in which it is stated that the tape-worm was found 
in an infant five days old. 

The parasites may cause no disturbance and are rarely dangerous. A 



DISEASES CAUSED BY CESTODES. 



367 



knowledge of the existence of the worm is generally a source of worry and 
anxiety; the patient may have considerable distress and complain of ab- 
dominal pains, nausea, diarrhoea, and sometimes anaemia. Occasionally the 
appetite is ravenous. In women and in nervous patients the constitutional 
disturbance may be considerable, and we not infrequently see great mental 
depression and even hypochondria. Various nervous phenomena, such as 
chorea, convulsions, or epilepsy, are believed to be caused by the parasites. 
Such effects, however, are very rare. The Bothrioceplialus may cause a 
severe and even fatal form of anaemia, which has been described fully in 
a recent monograph by Schaumann, of Helsingfors. 

The diagnosis is never doubtful. The presence of the segments is dis- 
tinctive. The ova, too, may be recognized in the stools. It makes but little 
difference as to the form of tape-worm, but the ripe segments of the Tcenia 
saginata are larger and broader, and show differences in the generative 
system as already mentioned. 

The prophylaxis is most important. Careful attention should be given 
to three points. First, all tape-worm segments should be burned. They 
should never be thrown into the water-closet or outside; secondly, careful 
inspection of meat at the abattoirs; and thirdly, cooking the meat suffi- 
ciently to kill the parasites. 

In the case of the beef measles, the distribution of the parasites, as 
given by Ostertag, shows that the muscles of the jaw are much more fre- 
quently affected than other parts — 360 times, while other organs were 
infected but 55 times. Sometimes there are instances of general infec- 
tion. Stiles states that no exact statistics have been published for this 
country. In Berlin the proportion of cattle infected in 1892-'93 was about 
1 to 672. Cold storage kills the cysticercus usually within three weeks. 
The measles are more readily overlooked in beef than in pork, as they do 
not present such an opaque white color. 

In the examination of hogs for cysticerci " particular stress should be 
laid upon the tongue, the muscles of mastication, and the muscles of the 
shoulder, neck, and diaphragm" (Stiles). They may be seen very easily 
on the under surface of the tongue. American hogs are comparatively 
free. In Prussia one hog is infected in about every 637. Specimens have 
been found alive twenty-nine days after slaughtering. In the examination 
of 1,000 hogs in Montreal, Dr. Clement and I found 76 instances of cysti- 
cerci. For full details with reference to the inspection of meat for animal 
parasites, the practitioner is referred to the work of Dr. Stiles, in Bulletin 
jSFo. 19, United States Department of Agriculture, 1898. 

Treatment. — For two days prior to the administration of the reme- 
dies the patient should take a very light diet and have the bowels moved 
occasionally by a saline cathartic. The practitioner has the choice of a 
large number of drugs. As a rule, the male fern acts promptly and well. 
The ethereal extract, in 2-drachm doses, may be given fasting, and fol- 
lowed in the course of a couple of hours by a brisk purgative. This usually 
succeeds in bringing away a large portion, but not always the entire worm. 

A combination of the remedies is sometimes very effective. An in- 
fusion is made of pomegranate root, half an ounce; pumpkin seeds, 1 



368 



DISEASES DUE TO ANIMAL PARASITES. 



ounce; powdered ergot, a drachm; and boiling water, 10 ounces. To an 
emulsion of the male fern (a drachm of ethereal extract), made with acacia 
powder, 2 minims of croton oil are added. The patient should have had 
a low diet the previous day and have taken a dose of salts in the evening. 
The emulsion and infusion are mixed and taken fasting at nine in the 
morning. 

The pomegranate root is a very efficient remedy, and may be given as 
an infusion of the bark, 3 ounces of which may be macerated in 10 ounces 
of water and then reduced to one half by evaporation. The entire quan- 
tity is then taken in divided doses. It occasionally produces colic, but is 
a very effective remedy. The active principle of the root, pelletierine, is 
now much employed. It is given in doses of 6 to 8 or even 10 grains, with 
a little tannin (grs. v) in sweetened water, and is followed in an hour by a 
purge. 

Pumpkin seeds are sometimes very efficient. Three or 4 ounces should 
be carefully bruised and then macerated for twelve or fourteen hours and 
the entire quantity taken and followed in an hour by a purge. Of other 
remedies, koosso, turpentine in ounce doses in honey, and kamala may be 
mentioned. 

Unless the head is brought away, the parasite continues to grow, and 
within a few months the segments again appear. Some instances are 
extraordinarily obstinate. Doubtless almost everything depends upon the 
exposure of the worm. The head and neck may be thoroughly protected 
beneath the valvulae conniventes, in which case the remedies may not act. 
Owing to its armature the taenia solium is more difficult to expel. It is 
probable that no degree of peristalsis could dislodge the head, and unless 
the worm is killed it does not let go its extraordinarily firm hold on the 
mucous membrane. If warm water be put in the commode the worm is less 
likely to contract and be broken. 

II. VlSCEKAL CESTODES. 

Whereas adult taenia? may give rise to little or no disturbance, and rarely, 
if ever, prove directly fatal, the affections caused by the larvae or immature 
forms in the solid organs are serious and important. There are two chief 
cestode larvae known to frequent man (a) the Cysticercus cellulosce, the 
larva of the Tamia solium, and (b) the Echinococcus, the larva of the Tamia 
echinococcus. The Cysticercus tcenice saginatce has been found only two or 
three times in man. 

I. Cysticercus cellulosae. — When man accidentally takes into his stom- 
ach the ripe ova of Tcenia solium he is liable to become the intermediate 
host, a part usually played for this tape-worm by the pig. This accident 
may occur in an individual the subject of Tcenia solium, in which case the 
mature proglottides either themselves wander into the stomach or, what 
is more likely, are forced into the organ in attacks of prolonged vomiting. 
Of course the accidental ingestion from the outside of a few ova is quite 
possible, and the liability of infection should always be borne in mind in 
handling the segments of the worm. 



DISEASES CAUSED BY CESTODES. 



369 



The symptoms depend entirely upon the number of ova ingested and 
the localities reached. In the hog the cysticerci produce very little dis- 
turbance. The muscles, the connective tissue, and the brain may be swarm- 
ing with the measles, as they are called, and yet the nutrition is maintained 
and the animal does not appear to be seriously incommoded. In the in- 
vasion period, if large numbers of the parasites are taken, there is, in all 
probability, constitutional disturbance; certainly this is seen in the calf, 
when fed with the ripe segments of Tcenia saginata. 

In man a few cysticerci lodged beneath the skin or in the muscles may 
cause no damage, and in time the larvae die and become calcified. They 
are occasionally found in dissection subjects or in post mortems as ovoid 
white bodies in the muscles or subcutaneous tissue. In this country they 
are very rare. I have seen but one instance in my post-mortem experience. 
Depending on the number and the locality specially affected, the symptoms 
may be grouped into general, cerebro-spinal, and ocular. In 155 cases com- 
piled by Stiles, the parasite in 117 was found in the brain, in 32 in the 
muscles, in 9 in the heart, in 3 in the lungs, subcutaneously in 5, in the liver 
in 2. 

(1) General. — As a rule the invasion of the larvae in man, unless in very 
large numbers, does not cause very definite symptoms. It occasionally 
happens, however, that a striking picture is produced. For instance, 
a patient was admitted to my wards very stiff and helpless, so much so 
that he had to be assisted upstairs and into bed. He complained of numb- 
ness and tingling in the extremities and general weakness, so that at first 
he was thought to have a peripheral neuritis. At the examination, how- 
ever, a number of painful subcutaneous nodules were discovered, which 
proved on excision to be the cysticerci. Altogether 75 could be felt sub- 
cutaneously, and from the soreness and stiffness they probably existed in 
large numbers in the muscles. There were none in his eyes, and he had 
no symptoms pointing to brain lesions. 

(2) Cerebrospinal. — Eemarkable symptoms may result from the pres- 
ence of the cysticerci in the brain and cord. In the silent region they may 
be abundant without producing any symptoms. I have in my possession 
the brain of a pig containing scores of " measles," yet the animal in the 
few moments in which I saw it just prior to death did not present any 
symptoms to attract attention. In the ventricles of the brain the cysti- 
cerci may attain a considerable size, owing to the fact that in regions in 
which they are unrestrained in their growth, as in the peritonaeum, the 
bladder-like body grows freely. When in the fourth ventricle, remarkable 
irritative symptoms may be produced. In 1884 I saw with Friedlander in 
Berlin a case from Kiess's wards in which during life there had been symp- 
toms of diabetes and anomalous nervous symptoms. Post mortem, the 
cysticercus was found beneath the valve of Vieussens, pressing upon the 
floor of the fourth ventricle. 

(3) Ocular. — Since von Graefe demonstrated the presence of the cysti- 
cercus in the vitreous humor many cases have been placed on record, and 
it is a condition easily recognized by oculists. 

Except in the eye, the diagnosis can rarely be made; when the cysti- 



370 



DISEASES DUE TO ANIMAL PARASITES. 



cerci are subcutaneous, one may be excised. It is possible that when 
numerous throughout the muscles they may be seen under the tongue, in 
which situation they may exist in the pig in numbers. 

II. Echinococcus Disease, — The hydatid worms or echinococci are the 
larvae of the Tcenia echinococcus of the dog. This is a tiny cestode not 
more than 4 or 5 mm. in length, consisting of only three or four segments, 
of which the terminal one alone is mature, and has a length of about 2 mm. 
and a breadth of 0.6 mm. The head is small and provided with four suck- 
ing disks and a rostellum with a double row of hooklets. This is an exceed- 
ingly rare parasite in the dog. Cobbold states that he has never met with 
a natural specimen in England. Leidy had not one in his large collection. 
I have not met with an instance in this country; Curtice, of Washington, 
found it once in an American dog. The only specimens in my cabinet I 
procured experimentally by feeding a dog with echinococcus cysts from an 
ox. The worms are so small that they may be readily overlooked, since 
they form small white, thread-like bodies closely adherent among the villi 
of the small intestines. The ripe segment contains about 5,000 eggs, 
which attain their development in the solid organs of various animals, 
particularly the hog and ox, more rarely the horse and the sheep. In some 
countries man is a common intermediate host, owing to the accidental 
ingestion of the ova. 

Development. — The little six-hooked embryo, freed from the eggshell 
by digestion, burrows through the intestinal wall and reaches the perito- 
neal cavity or the muscles; it may enter the portal vessels and be carried to 
the liver. It may enter the systemic vessels, and, passing the pulmonary 
capillaries, as it is protoplasmic and elastic, may reach the brain or other 
parts. Once having reached its destination, it undergoes the following 
changes: The hooklets disappear and the little embryo is gradually con- 
verted into a small cyst which presents two distinct layers — an external, 
laminated, cuticular membrane or capsule, and an internal, granular, par- 
enchymatous layer, the endocyst. The little cyst or vesicle contains a 
clear fluid. There is more or less reaction in the neighboring tissues, and 
the cyst in time has a fibrous investment. When this primary cyst or 
vesicle has attained a certain size, buds develop from the parenchymatous 
layer, which are gradually converted into cysts, presenting a structure iden- 
tical with that of the original cyst, namely, an elastic chitinous membrane 
lined with a granular parenchymatous layer. These secondary or daughter 
cysts are at first connected with the lining membrane of the primary 
cyst, but are soon set free. In this way the parent cyst as it grows may 
contain a dozen or more daughter cysts. Inside these daughter cysts a simi- 
lar process may occur, and from buds in the walls granddaughter cysts are 
developed. From the granular layer of the parent and daughter cysts buds 
arise which develop into brood capsules. From the lining membrane the 
little outgrowths arise and gradually develop into bodies known as scolices, 
which represent in reality the head of the Tcenia echinococcus and present 
four sucking disks and a circle of hooklets. Each scolex is capable when 
transferred to the intestines of a dog of developing into an adult tape-worm. 
The difference between the ovum of an ordinary tape-worm, such as the 



DISEASES CAUSED BY CESTODES. 



371 



Taenia solium, and the Tcenia echinococcus is in this way very striking. In 
the former case the ovum develops into a single larva — the Cysticercus cellu- 
loses — whereas the egg of the Tcenia echinococcus develops into a cyst which 
is capable of multiplying enormously and from the lining membrane of 
which millions of larval tape-worms develop. Ordinarily in man the de- 
velopment of the echinococcus takes place as above mentioned and by 
an endogenous form in which the secondary and tertiary cysts are con- 
tained within the primary; but in animals the formation may be different, 
as the buds from the primary cyst penetrate between the layers and develop 
externally, forming the exogenous variety. A third form is the multilocular 
echinococcus, in which from the primary cysts buds develop which are cut 
off completely and are surrounded by thick capsules of a connective tissue, 
which join together and ultimately form a hard mass represented by 
strands of connective tissue enclosing alveolar spaces about the size of 
peas or a little larger. In these spaces are found the remnants of the 
echinococcus cyst, occasionally the scolices or hooklets, but they are often 
sterile. 

The fluid of the echinococcus cysts is clear and limpid, and has a spe- 
cific gravity from 1.005 to 1.009. It does not contain albumin, but may 
contain traces of sugar. As a rule, the cysts, when not degenerated, con- 
tain the hydatid heads or scolices or the characteristic hooklets. 

Changes in the Cyst. — It is not known definitely how long the echino- 
coccus remains alive, but it probably lives many years — according to some 
authors as long as twenty years. The most common change is death and 
the gradual inspissation of the contents and conversion of the cyst into a 
mass containing putty-like or granular material which may be partially 
calcified. Eemnants of the chitinous cyst wall or hooklets may be found. 
These obsolete hydatid cysts are not infrequently found in the liver. A 
more serious termination is rupture, which may take place into a serous 
sac, or perforation may take place externally, when the cysts are discharged, 
as into the bronchi or alimentary canal or urinary passages. More un- 
favorable are the instances in which rupture occurs into the bile-passages 
or into the inferior cava. Eecovery may follow the rupture and discharge 
of the hydatids externally. Sudden death has been known to follow the 
rupture. A third and very serious mode of termination is suppuration, 
which may occur spontaneously or follow rupture and is found most fre- 
quently in the liver. Large abscesses may be formed which contain the 
hydatid membranes. 

Geographical Distribution of the Echinococcus. — The disease prevails 
most extensively in those countries in which man is brought into close 
contact with the dog, particularly when, as in Australia, the dogs are used 
extensively for herding sheep, the animal in which the larval form of the 
Tcenia echinococcus is most frequently found. In Iceland the cases are 
very numerous. In Europe the disease is not uncommon. In this country 
it is extremely rare and a great majority of all cases are in foreigners, 
tip to July, 1891, I have been able to find in the literature (and in the 
museums) only 85 cases in the United States and Canada. In the Ice- 
landic settlements of Manitoba many instances occur. A. H. Ferguson, who 



372 



DISEASES DUE TO ANIMAL PARASITES. 



has operated on a number of cases at the Winnipeg General Hospital, states 
that between forty-five and fifty persons with echinococcus disease have 
been treated in Winnipeg since 1874, the date of the Icelandic immigra- 
tion. 

Distribution in the Body. — Of the 1,862 cases comprised in the statis- 
tics of Davaine, Cobbold, Finsen, and Neisser, the parasites existed in the 
liver in 953, in the intestinal canal in 163, in the king or pleura in 153, in 
the kidneys, bladder, and genitals in 186, in the brain and spinal canal in 
127, bone 61, heart and blood-vessels 61, other organs 158. Of the 85 
cases in this country, the liver was the seat of the disease in 59. Of 50 
consecutive cases treated by Mosler at the Greifswald clinic, 36 involved 
the liver, 10 the lungs, 3 the right kidney, and 1 the spleen. 

Symptoms. — (a) Hydatids of the Liver. — Small cysts may cause no 
disturbance; large and growing cysts produce signs of tumor of the liver 
with great increase in the size of the organ. Naturally the physical signs 
depend much upon the situation of the growth. Near the anterior sur- 
face in the epigastric region the tumor may form a distinct prominence 
and have a tense, firm feeling, sometimes with fluctuation. A not infre- 
quent situation is to the left of the suspensory ligament, the resulting tu- 
mor pushing up the heart and causing an extensive area of dulness in the 
lower sternal and left hypochondriac regions. In the right lobe, if the 
tumor is on the posterior surface, the enlargement of the organ is chiefly 
upward into the pleura and the vertical area of dulness in the posterior 
axillary line is increased. Superficial cysts may give what is known as the 
hydatid fremitus. If the tumor is palpated lightly with the fingers of the 
left hand and percussed at the same time with those of the right, there is 
felt a vibration or trembling movement which persists for a certain time. 
It is not always present, and it is doubtful whether it is peculiar to the 
hydatid tumors or is due, as Briangon held, to the collision of the daugh- 
ter cysts. Very large cysts are accompanied by feelings of pressure or 
dragging in the hepatic region, sometimes actual pain. The general con- 
dition of the patient is at first good and the nutrition little, if at all, in- 
terfered with. Unless some of the accidents already referred to occur, the 
symptoms indeed may be trifling and due only to the pressure or weight 
of the tumor. 

Suppuration of the cyst changes the clinical picture into one of pyaemia. 
There are rigors, sweats, more or less' jaundice, and rapid loss of weight. 
Perforation may occur into the stomach, colon, pleura, bronchi, or exter- 
nally, and in some instances recovery has taken place. Perforation into 
the pericardium and inferior vena cava is fatal. In the latter case the 
daughter cysts have been found in the heart, plugging the tricuspid ori- 
fice and the pulmonary artery. Perforation of the bile-passages causes 
intense jaundice, and may lead to suppurative cholangitis. 

An interesting symptom connected with the rupture of hydatid cysts 
is the development of urticaria, which may also follow aspiration of the 
cysts. Brieger has separated a highly toxic material from the fluid, and to 
it the symptoms of poisoning may be due. 

Diagnosis. — Cysts of moderate size may exist without producing symp- 



DISEASES CAUSED BY CESTODES. 373 

toms. Large multiple echinococci may cause great enlargement with 
irregularity of the outline, and such a condition persisting for any time 
with retention of the health and strength suggests hydatid disease. An 
irregular, painless enlargement, particularly in the left lobe, or the pres- 
ence of a large, smooth, fluctuating tumor of the epigastric region is also 
very suggestive, and in this situation, when accessible to palpation, it 
gives a sensation of a smooth elastic growth and possibly also the hydatid 
tremor. When suppuration occurs the clinical picture is really that of 
abscess, and only the existence of previous enlargement of the liver with 
good health would point to the fact that the suppuration was associated 
with hydatids. Syphilis may produce irregular enlargement without much 
disturbance in the health, sometimes also a very definite tumor in the 
epigastric region, but this is usually firm and not fluctuating. The clinical 
features may simulate cancer very closely. In a case which I reported the 
liver was greatly enlarged and there were many nodular tumors in the 
abdomen. The post mortem showed enormous suppurating hydatid cysts 
in the left lobe of the liver which had perforated the stomach in two 
places and also the duodenum. The omentum, mesentery, and pelvis also 
contained numerous cysts. As a rule, the clinical course of the disease 
would suffice to separate it clearly from cancer. Dilatation of the gall- 
bladder and hydronephrosis have both been mistaken for hydatid disease. 
In the former the mobility of the tumor, its shape, and the mucoid char- 
acter of the contents suffice for the diagnosis. In some instances of hydro- 
nephrosis only the exploratory puncture could distinguish between the 
conditions. More frequent is the mistake of confounding a hydatid cyst 
of the right lobe pushing up the pleura with pleural effusion of the right 
side. The heart may be dislocated, the liver depressed, and dulness, feeble 
breathing, and diminished fremitus are present in both conditions. Fre- 
richs lays stress upon the different character of the line of dulness; in the 
echinococcus cyst the upper limit presents a curved line, the maximum 
of which is usually in the scapular region. Suppurative pleurisy may be 
caused by the perforation of the cyst. If adhesions result, the perforation 
takes place into the lung, and fragments of the cysts or small daughter 
cysts may be coughed up. For diagnostic purposes the exploratory punc- 
ture should be used. As stated, the fluid is usually perfectly clear or slightly 
opalescent, the reaction is neutral, and the specific gravity varies from 1.005 
to 1.009. It is non-albuminous, but contains chlorides and sometimes traces 
of sugar. Hooklets may be found either in the clear fluid or in the sup- 
purating cysts. They are sometimes absent, however, as the cyst may be 
sterile. 

(b) Echinococcus of the Respiratory System. — Of 809 cases of single 
hydatid cyst collected by Thomas in Australia, the lung was affected in 
134 cases. The larvae may develop primarily in the pleura and attain a 
large size. The symptoms are at first those of compression of the lung 
and dislocation of the heart. The physical signs are those of fluid in the 
pleura and the condition could scarcely be distinguished from ordinary 
effusion. The line of dulness may be quite irregular. As in the echino- 
coccus of the liver, the general condition of the patient may be excellent 



374 



DISEASES DUE TO ANIMAL PARASITES. 



in spite of the existence of extensive disease. Pleurisy is rarely excited. 
The cysts may become inflamed and perforate the chest wall. In a case 
of D. F. Smith's, of Walkertown, Ontario, a girl, aged twenty, had a run- 
ning sore in the eighth left intercostal space. This was freely opened, 
and in the pus which flowed out were a number of well-characterized echino- 
coccus cysts of various sizes. The patient recovered. 

Echinococci occur more frequently in the lung than in the pleura. If 
small, they may exist for some time without causing serious symptoms. 
In their growth they compress the lung and sooner or later lead to inflam- 
matory processes, often to gangrene, and the formation of cavities which 
connect with the bronchi. Fragments of membrane or small cysts may be 
expectorated. Haemorrhage is not infrequent. Perforation into the pleura 
with empyema is common. A majority of the cases are regarded during 
life as either phthisis or gangrene, and it is only the detection of the char- 
acteristic membranes or the hooklets which leads to the diagnosis. The 
condition is usually fatal; only a few cases have recovered. Of the 85 
American cases, in 6 the cysts occurred in the lung or pleura. 

(c) Ecliinococcus of the Kidneys. — In the collected statistics referred 
to above the genito-urinary system comes second as the seat of hydatid 
disease, though here the affection is rare in comparison with that of the 
liver. Of the 85 American cases, there were only 3 in which the kidneys 
or bladder were involved. The kidney may be converted into an enormous 
cyst resembling a hydronephrosis. 

The diagnosis is only possible by puncture and examination of the 
fluid. The cyst may perforate into the pelvis of the kidney, and portions 
of the membrane or cysts may be discharged with the urine, sometimes 
producing renal colic. I have reported a case in which for many months 
the patient passed at intervals numbers of small cysts with the urine. The 
general health was little if at all disturbed, except by the attacks of colic 
during the passage of the parasites. 

(d) Ecliinococcus of the Nervous System. — In this country very few in- 
stances have occurred in the brain. One or two reports indicate clearly 
that the common cystic disease of the choroidal plexuses has been mistaken 
for hydatids. Davies Thomas, of Australia, has tabulated 97 cases, includ- 
ing some of the Cysticercus cellulosce. According to his statistics, the cyst 
is more common on the right than on the left side, and is most frequent 
in the cerebrum. 

The symptoms are very indefinite, as a rule, being those of tumor. 
Persistent headache, convulsions, either limited or general, and gradually 
developing blindness have been prominent features in many cases. 

Muitilocular Ecliinococcus. — This form merits a brief separate descrip- 
tion, as it differs so remarkably from the usual type of the disease. It has 
been met with only in Bavaria, Wiirtemberg, the adjacent districts of 
Switzerland, and in the Tyrol. Possett has reported 13 cases from von 
Eokitansky's clinic at Innsbruck. In this country two cases have been 
reported, both in Germans. Delafield and Prudden's patient had been here 
five years, and for a year before his death had been jaundiced. A fluctuat- 
ing tumor was found in the right flank, apparently connected with the 



PARASITIC ARACHNIDA. 



375 



liver. This was opened, and death followed from haemorrhage. In Oer- 
tel's case the patient had lived here ten years. He was deeply jaundiced, 
and had a tumor mass at the right border of the liver, which was enlarged. 
Dr. Bacon, Jr., resected a cyst from the left lobe of the liver. The 
primary tumor presents irregularly formed cavities separated from each 
other by strands of connective tissue, and lined with the echinococcus 
membrane. The cavifies are filled with a gelatinous material, so that the 
tumor has very much the appearance of an alveolar colloid cancer. It is 
quite possible that a special form of tamia echinococcus represents the 
adult type of this peculiar parasite. This form is almost exclusively 
confined to the liver, and the symptoms resemble more those of tumor or 
cirrhosis. The liver is, as a rule, enlarged and smooth, not irregular as 
in presence of the ordinary echinococcus. Jaundice is a common symptom. 
The spleen is usually enlarged, there is progressive emaciation, and toward 
the close haemorrhages are common. 

Treatment of Echinococcus Disease. — Medicines are of no 
avail. Post-mortem reports show that in a considerable number of cases 
the parasite dies and the cyst becomes harmless. Operative measures should 
be resorted to when the cyst is large or troublesome. The simple aspira- 
tion of the contents has been successful in a large number of cases, and as 
it is not in any way dangerous, it may be tried before the more radical 
procedure of incision and evacuation of the cysts. Suppuration has oc- 
casionally followed the puncture. Injections into the sac should not be 
practised. With modern methods surgeons now open and evacuate the 
echinococcus cysts with great boldness, and the Australian records, which 
are the most numerous and important on this subject, show that recovery 
is the rule in a large proportion of the cases. Suppurative cysts in the 
liver should be treated as abscess. Naturally the outlook is less favorable. 
The practical treatment of hydatid disease has been greatly advanced 
by Australian surgeons. The works of the Australian physicians James 
Graham and Thomas may be consulted for interesting details in diagnosis 
and treatment. 



VI. PARASITIC ARACHNIDA. 

(1) Peiltastomes. — (a) Linguatula rhinaria (Pentastoma tcenioides) has 
a somewhat lancet-shaped body, the female being from 3 to 4 inches in 
length, the male about an inch in length. The body is tapering and marked 
by numerous rings. The adult worm infests the frontal sinuses and nostrils 
of the dog, more rarely of the horse. The larval form, which is known as 
the Linguatula serrata (Pentastomum denticulatum,), is seen in the internal 
organs, particularly the liver, but has also been found in the kidney. The 
adult worm has been found in the nostril of man, but is very rare and 
seldom occasions any inconvenience. The larvae are by no means uncom- 
mon, particularly in parts of Germany. 

(b) The P otocephalus conslvictus (Pentastomum constrict um), which is 
about the length of half an inch, with twenty-three rings on the abdomen, 



376 



DISEASES DUE TO ANIMAL PARASITES. 



was found by Aitken in the liver and hmgs of a soldier of a West Indian 
regiment. 

The parasite is very rare in this country. Flint refers to a Missouri 
case in which from 75 to 100 of the parasites were expectorated. The 
liver was enlarged and the parasites probably occupied this region. In 
1869 I saw a specimen which had been passed with the urine by a patient 
of James H. Kichardson, of Toronto. 

(2) Demodex (Acarus) folliculorum (var. hominis). — A minute para- 
site, from 0.3 mm. to 0.4 mm. in length, which lives in the sebaceous folli- 
cles, particularly of the face. It is doubtful whether it produces any symp- 
toms. Possibly when in large numbers they may excite inflammation of 
the follicles, leading to acne. 

(3) Sarcoptes (Aeams) scabiei (Itch Insect). — This is the most impor- 
tant of the arachnid parasites, as it produces troublesome and distressing 
skin eruptions. The male is 0.23 mm. in length and 0.19 mm. in breadth; 
the female is 0.45 mm. in length and 0.35 mm. in width. The female can 
be seen readily with the naked eye and has a pearly-white color. It is not 
so common a parasite in the United States and Canada as in Europe. 

The insect lives in a small burrow, about 1 cm. in length, which it makes 
for itself in the epidermis. At the end of this burrow the female lives. 
The male is seldom found. The chief seat of the parasite is in the folds 
where the skin is most delicate, as in the web between the fingers and toes, 
the backs of the hands, the axilla, and the front of the abdomen. The head 
and face are rarely involved. The lesions which result from the presence 
of the itch insect are very numerous and result largely from the irritation 
of the scratching. The commonest is a papular and vesicular rash, or, in 
children, an ecthymatous eruption. The irritation and pustulation which 
follow the scratching may completely destroy the burrows, but in typical 
cases there is rarely doubt as to the diagnosis. 

The treatment is simple. It should consist of warm baths with a thor- 
ough use of a soft soap, after which the .skin should be anointed with sul- 
phur ointment, which in the case of children should be diluted. An oint- 
ment of naphthol (drachm to the ounce) is very efficacious. 

(4) Leptus autumnalis (Harvest Bug). — This reddish-colored parasite, 
about half a millimetre in size, is often found in large numbers in fields 
and in gardens. They attach themselves to animals and man with their 
sharp proboscides, and the hooklets of their legs produce a great deal of 
irritation. They are most frequently found on the legs. They are readily 
destroyed by sulphur ointment or corrosive-sublimate lotions. 

Several varieties of ticks are occasionally found on man — the Ixodes 
ricinus and the Dermacentor americanus, which are met with in horses 
and oxen. 

VII. PARASITIC INSECTS. 

(1) Pediculi (Phthiriasis ; Pediculosis). — There are three varieties of the 
body louse, which are found only in persons of uncleanly habits. 

Pediculus capitis. — The male is from 1 to 1.5 mm. in length and the 



PARASITIC INSECTS. 



37? 



female nearly 2 mm. The color varies somewhat with the different races 
of men. It is light gray with a black margin in the European, and very 
much darker in the negro and Chinese. They are oviparous, and the female 
lays about sixty eggs, which mature in a week. The ova are attached to 
the hairs, and can be readily seen as white specks, known popularly as nits. 
The symptoms are irritation and itching of the scalp. When numerous 
the insects may excite an eczema or a pustular dermatitis, which causes 
crusts and scabs, particularly at the back of the head. In the most extreme 
cases the hair becomes tangled in these crusts and matted together, form- 
ing at the occiput a firm mass which is known as plica polonica, as it was 
not infrequent among the Jewish inhabitants of Poland. 

Pediculus corporis (vestimentorum). — This is considerably larger than 
the head louse. It lives on the clothing, and in sucking the blood causes 
minute hsemorrhagic specks, which are very common about the neck, back, 
and abdomen. The irritation of the bites may cause urticaria, and the 
scratching is usually in linear lines. In long-standing cases, particularly 
in old dissipated characters, the skin becomes rough and greatly pigmented, 
a condition which has been termed the vagabond's disease — morbus errorum 
— and which may be mistaken for the bronzing of Addison's disease. 

Phthirius pubis differs somewhat from the other forms, and is found 
in the parts of the body covered with short hairs, as the pubes; more rarely 
the axilla and eyebrows. 

The taches bleudtres are stated by French writers to be excited by the 
irritation of pediculi. 

Treatment. — For the Pediculus capitis, when the condition is very 
bad, the hair should be cut short, as it is very difficult to destroy thor- 
oughly all the nits. Repeated saturations of the hair in coal-oil or in tur- 
pentine are usually efficacious, or with lotions of carbolic acid, 1 to 50. 
Scrupulous cleanliness and care are sufficient to prevent recurrence. In 
the case of the Pediculus corporis the clothing should be placed for sev- 
eral hours in a disinfecting oven. To allay the itching a warm bath con- 
taining 4 or 5 ounces of bicarbonate of soda is useful. The skin may be 
rubbed with a lotion of carbolic acid, 2 drachms to the pint, with 2 ounces 
of glycerin. For the Phthirius pubis white precipitate or ordinary mer- 
curial ointment should be used, and the parts should be thoroughly washed 
two or three times a day with soft soap and water. 

(2) Cimex lectularius (Common Bed-bug). — This parasite is from 3 to 
4 mm. in length and has a reddish-brown color. It lives in the crevices of 
the bedstead and in the cracks in the floor and in the walls. It is noc- 
turnal in its habits. The peculiar odor of the insect is caused by the secre- 
tion of a special gland. The parasite possesses a long proboscis, with which 
it sucks the blood. Individuals differ remarkably in the reaction to the 
bite of this insect; some are not disturbed in the slightest by them, in 
others the irritation causes hyperemia and often intense urticaria. Fumi- 
gation with sulphur or scouring with corrosive-sublimate solution or kero- 
sene destroys them. Iron bedsteads should be used. 

(3) Pulex irritans (The Common Flea). — The male is from 2 to 2.5 
mm. in length, the female from 3 to 4 mm. The flea is a transient para- 



378 



DISEASES DUE TO ANIMAL PARASITES. 



site on man. The bite causes a circular red spot of hyperemia in the centre 
of which is a little speck where the boring apparatus has entered. The 
amount of irritation caused by the bite is variable. Many persons suffer 
intensely and a diffuse erythema or an irritable urticaria develops; others 
suffer no inconvenience whatever. 

The Pulex penetrans (sand-flea; jigger) is found in tropical countries, 
particularly in the West Indies and South America. It is much smaller 
than the common flea, and not only penetrates the skin, but burrows and 
produces an inflammation with pustular or vesicular swelling. It most 
frequently attacks the feet. It is readily removed with a needle. Where 
they exist in large numbers the essential oils are used on the feet as a 
preventive. 

VIII. MYIASIS. 

Of these, the most important are the larvae of certain diptera, particu- 
larly the flesh flies — Creophila. The condition is called myiasis. 

The most common form is that in which an external wound becomes 
living, as it is called. This myiasis vulnerum is caused by the larvae of 
either the" blue-bottle or the common flesh fly. The larvae of the Lucilia 
macellaria, the so-called screw-worm, have been found in the nose, in 
wounds, and in the vagina after delivery. They can be removed readily 
with the forceps; if there is any difficulty, thorough cleansing and the 
application of an antiseptic bandage is sufficient to kill them. The ova 
of these flies may be deposited in the nostrils, the ears, or the conjunctiva — 
the myiasis narium, aurium, conjunctivae. This invasion rarely takes place 
unless these regions are the seat of disease. In the nose and in the ear the 
larvae may cause serious inflammation. 

The cutaneous myiasis may be caused by the larvae of the Musca vomi- 
toria, but more commonly by the bot-flies of the ox and sheep, which 
occasionally attack man. This condition is rare in temperate climates. 
Matas has described a case in which oestrus larvae were found in the glu- 
teal region. In parts of Central America the eggs of another bot-fly, the 
Dermatobia, are not infrequently deposited in the skin and produce a 
swelling very like the ordinary boil. 

A specimen of the Homalomyia scalaris, one of the privy flies, was sent 
to me by Dr. Hartin, of Kaslo City, British Columbia, the. larvae of which 
were passed in large numbers in the stools of a man aged twenty-four, 
a native of Louisiana. They were present in the stools from May 1 to July 
15, 1897. ' 

Myiasis interna may result from the swallowing of the larvae of the 
common house fly or of species of the genus Anfhomyia. There are many 
cases on record in which the larvae of the Musca domestica have been dis- 
charged by vomiting. Instances in which dipterous larvae have been passed 
in the faeces are less common. Finlayson, of Glasgow, has recently re- 
ported an interesting case in a physician, who, after protracted constipa- 
tion and pain in the back and sides, passed large numbers of the larvae 
of the flower fly — Antliomyia canicularis. Among other forms of larvae 



MYIASIS. 



379 



or gentles, as they are sometimes called, which have been found in the 
faeces, are those of the common house fly, the blue-bottle fly, and the 
Tecliomyza fusca. The, larvae of other insects are extremely rare. It is 
stated that the caterpillar of the tabby moth has been found in the faeces. 

Here may be mentioned among the effects of insects the remarkable 
urticaria epidemica, which is caused in some districts by the procession 
caterpillars, particularly the species Cnethocampa. There are districts in 
the Kahlberger Schweiz which have been rendered almost uninhabitable 
by the irritative skin eruptions caused by the presence of these insects, the 
.action of which is not necessarily in consequence of actual contact with 
them. 

In Africa the larvse of the Cayor fly are not uncommonly found be- 
neath the skin, in little boils. 



24 



< 



SECTION IIL 
THE INTOXICATIONS 

AND SUN-STKOKE. 



I. ALCOHOLISM. 

(1) Acute Alcoholism. — When a large quantity of alcohol is taken, its 
influence on the nervous system is manifested in muscular incoordina- 
tion, mental disturbance, and, finally, narcosis. The individual presents 
a flushed, sometimes slightly cyanosed face, a full pulse, with deep but rarely 
stertorous respirations. The pupils are dilated. The temperature is fre- 
quently below normal, particularly if the patient has been exposed to cold. 
Perhaps the lowest reported temperatures have been in cases of this sort. 
An instance is on record in which the patient on admission to hospital had 
a temperature of 24° C. (ca. 75° F.), and ten hours later the temperature 
had not risen to 91°. The unconsciousness is rarely so deep that the pa- 
tient cannot be roused to some extent, and in reply to questions he mutters, 
incoherently. Muscular twitchings may occur, but rarely convulsions. 
The breath has a heavy alcoholic odor. 

The diagnosis is not difficult, yet mistakes are frequently made. Per- 
sons are sometimes brought to hospital by the police supposed to be drunk 
when in reality they are dying from apoplexy. Too great care cannot be 
exercised, and the patient should receive the benefit of the doubt. In 
some instances the mistake has arisen from the fact that a person who has 
been drinking heavily has been stricken with apoplexy. In this condition 
the coma is usually deeper, stertor is present, and there may be evidence of 
hemiplegia in the greater flaccidity of the limbs on one side. The subject 
will be considered in the section upon ursemic coma. 

Dipsomania is a form of acute alcoholism seen in persons with a strong 
hereditary tendency to drink. Periodically the victims go " on a spree,"' 
but in the intervals they are entirely free from any craving for alcohol. 

(2) Chronic Alcoholism. — In moderation, wine, beer, and spirits may 
be taken throughout a long life without impairing the general health. 

According to Payne, the poisonous effects of alcohol are manifested (1) 
as a functional poison, as in acute narcosis; (2) as a tissue poison, in which 
its effects are seen on the parenchymatous elements, particularly* epithe- 
380 



ALCOHOLISM. 



381 



Hum and nerve, producing a slow degeneration, and on the blood-vessels, 
causing thickening and ultimately fibroid changes; and (3) as a checker 
of tissue oxidation, since the alcohol is consumed in place of the fat. This 
leads to fatty changes and sometimes to a condition of general steatosis. 

The chief effects of chronic alcohol poisoning may be thus summa- 
rized. 

Nervous System. — Functional disturbance is common. Unsteadiness 
of the muscles in performing any action is a constant feature. The tremor 
is best seen in the hands and in the tongue. The mental processes may 
be dull, particularly in the early morning hours, and the patient is unable 
to transact any business until he has had his accustomed stimulant. Irri- 
tability of temper, forgetfulness, and a change in the moral character of 
the individual gradually come on. The judgment is seriously impaired, 
the will enfeebled, and in the final stages dementia may supervene. The 
relation of chronic alcoholism to insanity has been much discussed. Ac- 
cording to Savage, of 4,000 patients admitted to the Bethlehem Hospital, 
133 gave drink as the cause of their insanity. Chronic alcoholism is be- 
lieved by many to be one of the special causes of dementia paralytica, but 
the opinions of experts on this question are still discordant. Savage states 
that not more that 7 per cent are caused by alcohol alone. In many cases 
it is certainly one of the important elements in the strain which leads to 
this breakdown. Epilepsy may result directly from chronic drinking. It 
is a hopeful form, and may disappear entirely with a return to habits of 
temperance. 

No characteristic changes are found in the nervous system. Haemor- 
rhagic pachymeningitis is not very uncommon. Opacity and thickening 
of the pia-arachnoid membranes, with more or less wasting of ^he convo- 
lutions, generally occur. These are in no way peculiar to chronic alcohol- 
ism, but are found in old persons and in chronic wasting diseases. In the 
very protracted cases there may be chronic encephalo-meningitis with ad- 
hesions of the membranes. Finer changes in the nerve-cells, their pro- 
cesses, and the neuroglia have been described by Berkley, Hoch, and others. 
By far the most striking effect of alcohol on the nervous system is the pro- 
duction of the alcoholic neuritis, which will be considered later. 

Digestive System. — Catarrh of the stomach is the most common symp- 
tom. The toper has a furred tongue, heavy breath, and in the morning a 
sensation of sinking at the stomach until he has had his dram. The appe- 
tite is usually impaired and the bowels are constipated. In beer-drinkers 
dilatation of the stomach is common. 

Alcohol produces definite changes in the liver, leading ultimately to 
the various forms of cirrhosis, to be described. In Welch's laboratory J. 
Friedenwald has caused typical cirrhosis in rabbits by the administration 
of alcohol. The effect is probably a primary degenerative change in the 
liver-cells, although many good observers still hold that the poison acts 
first upon the connective-tissue elements. It is probable that a special 
vulnerability of the liver-cells is necessary in the etiology of alcoholic 
cirrhosis. There are cases in which comparatively moderate drinking for 
a few years has been followed by cirrhosis; on the other hand, the livers 



382 



THE INTOXICATIONS AND SUN-STROKE. 



of persons who have been steady drinkers for thirty or forty years may 
show only a moderate grade of sclerosis. For years before cirrhosis develops 
heavy drinkers may present an enlarged and tender liver, with at times 
swelling of the spleen. With the gastric and hepatic disorders the facies 
often becomes very characteristic. The venules of the cheeks and nose are 
dilated; the latter becomes enlarged, reel, and may present the condition 
known as acne rosacea. The eyes are watery, the conjunctivas hypersemic 
and sometimes bile-tinged. 

The lieart and arteries in chronic topers show important degenerative 
changes. Alcoholism is one of the special factors in causing arterio- 
sclerosis. Steell has pointed out the frequency of cardiac dilatation in 
these cases. 

Kidneys. — The influence of chronic alcoholism upon these organs is 
by no means so marked. According to Dickinson the total of renal disease 
is not greater in the drinking class, and he holds that the effect of alcohol 
on the kidneys has been much overrated. Formad has directed attention 
to the fact that in a large proportion of chronic alcoholics the kidneys are 
increased in size. The Guy's Hospital statistics support this statement, 
and Pitt notes that in 43 per cent of the bodies of hard drinkers the kidneys 
were hypertrophied without showing morbid change. The typical granu- 
lar kidney seems to result indirectly from alcohol through the arterial 
changes. 

It was formerly thought that alcohol was in some way antagonistic to 
tuberculous disease, but the observations of late years indicate clearly that 
the reverse is the case and that chronic drinkers are much more liable to 
both acute and pulmonary tuberculosis. It is probably altogether a ques- 
tion of altered tissue-soil, the alcohol lowering the vitality and enabling the 
bacilli more readily to develop and grow. 

(3) Delirium Tremens {mania a potu) is really only an incident in the 
history of chronic alcoholism, and results from the long-continued action 
of the poison on the brain. The condition was first accurately described 
early in this century by Sutton, of G-reenwich, who had numerous oppor- 
tunities for studying the different forms among the sailors. One of the 
most thorough and careful studies of the disease was made by Ware, of 
Boston. A spree in a temperate person, no matter how prolonged, is rarely 
if ever followed by delirium tremens; but in the case of an habitual 
drinker a temporary excess is apt to bring on an attack. It sometimes 
develops in consequence of the sudden withdrawal of the alcohol. There 
are circumstances which in a heavy drinker determine, sometimes with 
abruptness, the onset of delirium. Such are an accident, a sudden fright 
or shock, and an acute inflammation, particularly pneumonia. At the 
outset of the attack the patient is restless and depressed and sleeps badly, 
symptoms which cause him to take alcohol more freely. After a day or 
two the characteristic delirium sets in. The patient talks constantly and 
incoherently; he is incessantly in motion, and desires to go out and attend 
to some imaginary business. Hallucinations of sight and hearing develop. 
He sees objects in the room, such as rats, mice, or snakes, and fancies that 
they are crawling over his body. The terror inspired by these imaginary 



ALCOHOLISM. 



383 



objects is great, and has given the popular name " horrors " to the disease. 
The patients need to be watched constantly, for in their delusions they 
may jump out of the window or escape. Auditory hallucinations are not 
so common, but the patient may complain of hearing the roar of animals 
or the threats of imaginary enemies. There is much muscular tremor; 
the tongue is covered with a thick white fur, and when protruded is tremu- 
lous. The pulse is soft, rapid, and readily compressed. There is usually 
fever, but the temperature rarely registers above 102° or 103°. In fatal 
cases it may be higher. Insomnia is a constant feature. On the third or 
fourth day in favorable cases the restlessness abates, the patient sleeps, 
and improvement gradually sets in. The tremor persists for some days, 
the hallucinations gradually disappear, and the appetite returns. In more 
serious cases the insomnia persists, the delirium is incessant, the pulse be- 
comes more frequent and feeble, the tongue dry, the prostration extreme, 
and death takes place from gradual heart-failure. 

Diagnosis. — The clinical picture of the disease can scarcely be con- 
founded with any other. Cases with fever, however, may be mistaken for 
meningitis. By far the most common error is to overlook some local dis- 
ease, such as pneumonia or erysipelas, or an accident, as a fractured rib, 
which in a chronic drinker may precipitate an attack of delirium tremens. 
In every instance a careful examination should be made, particularly of 
the lungs. It is to be remembered that in the severer forms, particularly 
the febrile cases, congestion of the bases of the lungs is by no means un- 
common. Another point to be borne in mind is the fact that pneumonia 
of the apex is apt to be accompanied by delirium similar to mania a potu. 

Prognosis. — Eecovery takes place in a large proportion of the cases 
in private practice. In hospital practice, particularly in the large city 
hospitals to which the debilitated patients are taken, the death-rate is 
higher. Gerhard states that of 1,241 cases admitted to the Philadelphia 
Hospital 121 proved fatal. Eecurrence is frequent, almost indeed the rule, 
if the drinking is kept up. 

Treatment. — Acute alcoholism rarely requires any special measures, 
as the patient sleeps off the effects of the debauch. In the case of pro- 
found alcoholic coma it may be advisable to wash out the stomach, and if 
collapse symptoms occur the limbs should be rubbed and hot applications 
made to the body. Should convulsions supervene, chloroform may be 
carefully administered. In the acute, violent alcoholic mania the hypo- 
dermic injection of apomorphia, one eighth or one sixth of a grain, is 
usually very effectual, causing nausea and vomiting, and rapid disappear- 
ance of the maniacal symptoms. 

Chronic alcoholism is a condition very difficult to treat, and once fully 
established the habit is rarely abandoned. The most obstinate cases are 
those with marked hereditary tendency. Withdrawal of the alcohol is the 
first essential. This is most effectually accomplished by placing the pa- 
tient in an institution, in which he can be carefully watched during the 
trying period of the first week or ten days of abstention. The absence of 
temptation in institution life is of special advantage. For the sleepless- 
ness the bromides or hyoscine may be employed. Quinine and strychnine 



384 



THE INTOXICATIONS AND SUN-STROKE. 



in tonic doses may be given. Cocaine or the fluid extract of coca has been 
recommended as a substitute for alcohol, but it is not of much service. 
Prolonged seclusion in a suitable institution is in reality the only effectual 
means of cure. When the hereditary tendency is strongly developed a lapse 
into the drinking habit is almost inevitable. 

In delirium tremens the patient should be confined to bed and care- 
fully watched night and day. The danger of escape in these cases is very 
great, as the patient imagines himself pursued by enemies or demons. 
Flint mentions the case of a man who escaped in his night-clothes and ran 
barefooted for fifteen miles on the frozen ground before he was over- 
taken. The patient should not be strapped in bed, as this aggravates the 
delirium; sometimes, however, it may be necessary, in which case a sheet 
tied across the bed may be sufficient, and this is certainly better than vio- 
lent restraint by three or four men. Alcohol should be withdrawn at once 
unless the pulse is feeble. 

Delirium tremens is a disease which, in a large majority of cases, runs 
a course very slightly influenced by medicine. The indications for treat- 
ment are to procure sleep and to support the strength. In mild cases half 
a drachm of bromide of potassium combined with tincture of capsicum 
may be given every three hours. Chloral is often of great service, and may 
be given without hesitation unless the heart's action is feeble. Good re- 
sults sometimes follow the hypodermic use of hyoscine, one one-hundredth 
of a grain. Opium must be used cautiously. A special merit of Ware's 
work was the demonstration that on a rational or expectant plan of treat- 
ment the percentage of recoveries was greater than with the indiscriminate 
use of sedatives, which had been in vogue for many years. When opium is 
indicated it should be given as morphia, hypodermically. The effect should 
be carefully watched, and if after three or four quarter-grain doses have 
been given the patient is still restless and excited, it is best not to push it 
farther. When fever is present the tranquillizing effects of a cold douche 
or cold bath may be tried, or the cold pack. The large doses of digitalis 
formerly employed are not advisable. 

Careful feeding is the most important element in the treatment of 
these cases. Milk and concentrated broths should be given at stated inter- 
vals. If the pulse becomes rapid and shows signs of flagging alcohol may 
be given in combination with the aromatic spirits of ammonia. 



II. MORPHIA HABIT (MorpUnomania ; Morphinism). 

This habit arises from the constant use of morphia — taken at first, as a 
rule, for the purpose of allaying pain. The craving is gradually engen- 
dered, and the habit in this way acquired. The injurious effects vary 
very much, and in the East, where opium-smoking is as common as tobacco- 
smoking with us, the ill effects are, according to good observers, not so 
striking. 

The habit is particularly prevalent among women and physicians who 
use the hypodermic syringe for the alleviation of pain, as in neuralgia or 



MORPHIA HABIT. 



385 



.sciatica. The acquisition of the habit as a pure luxury is rare in this 
country. 

The symptoms at first are slight, and moderate doses may be taken for 
months without serious injury and without disturbance of health. There 
are exceptional instances in which for a period of years excessive amounts 
Iiave been taken without deterioration of the mental or bodily functions. 
As a rule, the dose necessary to obtain the desired sensation has grad- 
ually to be increased. As the effects wear off the victim experiences sensa- 
tions of lassitude and mental depression, accompanied often with slight 
nausea and epigastric distress, or even recurring colic, which may be mis- 
taken for appendicitis. The confirmed opium-eater usually has a sallow, 
pasty complexion, is emaciated, and becomes prematurely gray. He is 
restless, irritable, and unable to remain quiet for any time. Itching is a 
common symptom. The sleep is disturbed, the appetite and digestion are 
deranged, and except when directly under the influence of the drug the 
mental condition is one of depression. Occasionally there are profuse 
sweats, which may be preceded by chills. The pupils, except when under 
the direct influence of the drug, are dilated, sometimes unequal. Persons 
addicted to morphia are inveterate liars, and no reliance whatever can be 
placed upon their statements. In many instances this is not confined to 
matters relating to the vice. In women the symptoms may be associated 
with those of pronounced hysteria or neurasthenia. The practice may be 
•continued for an indefinite time, usually requiring increase in the dose 
until ultimately enormous quantities may be needed to obtain the desired 
effect. Finally a condition of asthenia is induced, in which the victim 
takes little or no food and dies from the extreme bodily debility. An 
increase in the dose is not always necessary, and there are habitues who reach 
the point of satisfaction with a daily amount of 2 or 3 grains of morphia, 
and who are able to carry on successfully for many years the ordinary busi- 
ness of life. They may remain in good physical condition, and indeed often 
look ruddy. 

The treatment of the morphia habit is extremely difficult, and can rarely 
be successfully carried out by the general practitioner. Isolation, sys- 
tematic feeding, and gradual withdrawal of the drug are the essential 
•elements. As a rule, the patients must be under control in an institution 
and should be in bed for the first ten days. It is best in a majority of 
cases to reduce the morphia gradually. The diet should consist of beef- 
juice, milk, and egg-white, which should be given at short intervals. The 
sufferings of the patients are usually very great, more particularly the ab- 
dominal pains, sometimes nausea and vomiting, and the distressing rest- 
lessness. Usually within a week or ten days the opium may be entirely 
withdrawn. In all cases the pulse should be carefully watched and, if 
feeble, stimulants should be given, with the aromatic spirits of ammonia 
and digitalis. For the extreme restlessness a hot bath is serviceable. The 
sleeplessness is the most distressing symptom, and various drugs may have 
to be resorted to, particularly hyoscine and sulphonal and sometimes, if 
the insomnia persist, morphia itself. 

It is essential in the treatment of a case to be certain that the patient 



386 



THE INTOXICATIONS AND SUN-STROKE. 



has no means of obtaining morphia. Even under the favorable circum- 
stances of seclusion in an institution, and constant watching by a night and 
a day nurse, I have known a patient to practice deception for a period of 
three months. After an apparent cure the patients are only too apt to 
lapse into the habit. 

The condition is one which has become so common, and is so much on 
the increase, that physicians should exercise the utmost caution in pre- 
scribing morphia, particularly to female patients. Under no circumstances 
whatever should a patient with neuralgia or sciatica be allowed to use the 
hypodermic syringe, and it is even safer not to intrust this dangerous 
instrument to the hands of the nurse. 



III. LEAD-POISONING {Plumhism; Saturnism). 

Etiology. — The disease is widespread, particularly in lead-workers-, 
and among plumbers, painters, and glaziers. The metal is introduced into 
the system in many forms. Miners usually escape, but those engaged in 
the smelting of lead-ores are often attacked. Animals in the neighbor- 
hood of smelting furnaces have suffered with the disease, and even the 
birds that feed on the berries in the neighborhood may be affected. Men 
engaged in the white-lead factories are particularly prone to plumbism. 
Accidental poisoning may come in many ways; most commonly by drink- 
ing water which has passed through lead pipes or been stored in lead- 
lined cisterns. Wines and cider which contain acids quickly become con- 
taminated in contact with lead. It was the frequency of colic in certain 
of the cider districts of Devonshire which gave the name of Devonshire colic, 
as the frequency of it in Poitou gave the name colica Pictonum. Among- 
the innumerable sources of accidental poisoning may be mentioned milk, 
various sorts of beverages, hair dyes, false teeth, and thread. A serious 
outbreak of lead-poisoning, which was investigated by David D. Stewart, 
occurred recently in Philadelphia, owing to the disgraceful adulteration 
of a baking-powder with chromate of lead, which was used to give- 
a yellow tint to the cakes. Lead given medicinally rarely produces poi- 
soning. 

All ages are attacked, but J. J. Putnam states that children are rela- 
tively less liable. The largest number of cases occur between thirty and 
forty. According to Oliver, from whose recent Goulstonian lectures I here 
quote, females are more susceptible than males. He states that they are 
much more quickly brought under its influence, and in a recent epidemic 
in which a thousand cases were involved the proportion of females to males 
was four to one. 

The lead gains entrance to the system through the lungs, the digestive 
organs, or the skin. Poisoning may follow the use of cosmetics contain- 
ing lead. Through the lungs it is freely absorbed. The chief channel, 
according to Oliver, is the digestive system. It is rapidly eliminated by 
the kidneys and skin, and is present in the urine of lead-workers. The 
susceptibility is remarkably varied. The symptoms may be manifest within 



LEAD-POISONING. 



38T 



a month of exposure. On the other hand, Tanquerel (des Planches) met 
with a case in a man who had been a lead-worker for fifty-two years. 

Morbid Anatomy. — Small quantities of lead occur in the body in 
health. J. J. Putnam's reports show that of 150 persons not presenting 
symptoms of lead-poisoning traces of lead occurred in the urine of 25 per 
cent. 

In chronic poisoning lead is found in the various organs. The affected 
muscles are yellow, fatty, and fibroid. The nerves present the features of 
a peripheral degenerative neuritis. The cord and the nerve-roots are, as a 
rule, uninvolved. In the primary atrophic form the ganglion cells of the 
anterior horns are probably implicated. In the acute fatal cases there may 
be the most intense entero-colitis. 

Clinical Forms. — Acute Poisoning. — We do not refer here to the 
accidental or suicidal cases, which present vomiting, pain in the abdomen, 
and collapse symptoms. In workers in lead there are several manifesta- 
tions which follow a short time after exposure and set in acutely. There 
may be, in the first place, a rapidly developing anaemia. Acute neuritis has- 
been described, and convulsions, epilepsy, and a delirium, which may be, 
as Stephen Mackenzie has noted, not unlike that produced by alcohol. 
There are also cases in which the gastro-intestinal symptoms are most 
intense and rapidly prove fatal. There was admitted under my care in the 
Philadelphia Hospital a painter, aged fifty, suffering with anaemia and 
severe abdominal pain, which had lasted about a week. He had vomiting, 
constipation at first, afterward severe diarrhoea and melaena, with distention 
and tenderness of the abdomen. There were albumin and tube-casts in the 
urine. The temperature was usually subnormal. Death occurred at the 
end of the second week. There was found the most intense entero-colitis 
with haemorrhages and exudation. These acute forms develop more fre- 
quently in persons recently exposed, and, according to Mackenzie, are more 
frequent in winter than in summer. Da Costa has reported a case of hemi- 
plegia developing after three days' exposure to the poison. 

Chronic poisoning presents the following symptoms: 

(a) Ancemia, the so-called saturnine cachexia, which may be profound. 
As a rule, however, the corpuscles do not sink below 50 per cent. In some 
of the chronic cases there may be a persistent pallor of the face with a tol- 
erably high blood-count. 

(h) Blue line on the gums, which is a valuable indication, but not invari- 
ably present. Two lines must be distinguished: one, at the margin be- 
tween the gums and teeth, is on, not in the gums, and is readily removed by 
rinsing the mouth and cleansing the teeth. The other is the well-known 
characteristic blue-black line at the margin of the gum. The color is not 
uniform, but being in the papillae of the gums the line is, as seen with a 
magnifying-glass, interrupted. The lead is absorbed and converted in the 
tissues into a black sulphide by the action of sulphuretted hydrogen from 
the tartar of the teeth. The line may form in a few days after exposure 
(Oliver) and disappear within a few weeks, or may persist for many months. 
Philipson lias noted the occurrence of a black line in miners, due to the 
deposition of carbon. 



388 



THE INTOXICATIONS AND SUN-STROKE. 



The most important symptoms of chronic lead-poisoning are colic, 
lead-palsy, and the encephalopathy. Of these, the colic is the most fre- 
quent. Of Tanquerel's cases, there were 1,217 of colic, 101 of paralysis, 
and 72 of encephalopathy. 

(c) Colic is the most common symptom of chronic lead-poisoning. It 
is often preceded by gastric or intestinal symptoms, particularly constipa- 
tion. The pain is over the whole abdomen. The colic is usually parox- 
ysmal, like true colic, and is relieved by pressure. There is often, in addi- 
tion, between the paroxysms a dull, heavy pain. There may be vomiting. 
During the attack, as Eiegel noted, the pulse is increased in tension and 
the heart's action is retarded. Attacks of pain with acute diarrhoea may 
recur for weeks or even for three or four years. 

(d) Lead-palsy. — This is rarely a primary manifestation. The onset 
may be acute, subacute, or chronic. It usually develops without fever. 
In its distribution it may be partial, limited to a muscle or to certain mus- 
cle groups, or generalized, involving in a short time the muscles of the 
extremities and the trunk. Madame Dejerine-Klumpke recognizes the 
following localized forms: 

(1) Antebrachial type, paralysis of the extensors of the fingers and of 
the wrist. In this the musculo-spiral nerve is involved, causing the char- 
acteristic wrist-drop. The supinator longus usually escapes. In the long- 
continued flexion of the carpus there may be slight displacement back- 
ward of the bones, with distention of the synovial sheaths, so that there 
is a prominent swelling over the wrist. This, which is sometimes known 
as Gruebler's tumor, though not of any moment, is often very annoying to 
the patient. 

(2) Brachial type, which involves the deltoid, the biceps, the brachi- 
alis anticus, and the supinator longus, rarely the pectorals. The atrophy 
is of the scapulo-humeral form. It is bilateral, and sometimes follows the 
first form, but it may be primary. 

(3) The Aran-Duchenne type, in which the small muscles of the hand 
and of the thenar and hypothenar eminences are involved, so that we have a 
paralysis closely resembling that of the early stage of polio-myelitis anterior 
chronica. The atrophy is marked, and may be the first manifestation of 
the lead-palsy. Mobius has shown that this form is particularly developed 
in tailors. 

(4) The, peroneal type. According to Tanquerel, the lower limbs are 
involved in the proportion of 13 to 100 of the upper limbs. The lateral 
peroneal muscles, the extensor communis of the toes, and the extensor 
proprius of the big toe are involved, producing the steppage gait. 

(5) Laryngeal form. Adductor paralysis has been noted by Morell 
Mackenzie and others in lead-palsy. 

Generalized Palsies. — There may be a slow, chronic paralysis, gradually 
involving the extremities, beginning with the classical picture of wrist- 
drop. More frequently there is a rapid generalization, producing complete 
paralysis in all the muscles of the parts in a few days. It may pursue a 
course like an ascending paralysis, associated with rapid wasting of all 
four limbs. Such cases, however, are very rare. Death has occurred by 



LEAD-POISONING. 



389 



involvement of the diaphragm. Oliver reports a case of Philipson's in 
which complete paralysis supervened. Dejerine-Klumpke also recognizes 
a febrile form of general paralysis in lead-poisoning, which may closely 
resemble the subacute spinal paralysis of Duchenne. 

There is also a primary saturnine muscular atrophy in which the weak- 
ness and wasting come on together and develop proportionately. It is this 
form, according to Gowers, which most frequently assumes the Aran- 
Duchenne type. 

The electrical reactions are those of lesions of the lower motor seg- 
ment, and will be described under diseases of the nerves. The degener- 
ative reaction in its different grades may be present, depending upon the 
severity of the disease. 

Usually with the onset of the paralysis there are pains in the legs and 
joints, the so-called saturnine arthralgias. Sensation may, however, be 
unaffected. 

(e) The cerebral symptoms are numerous. Optic neuritis or neuro- 
retinitis may develop. Hysterical symptoms occasionally occur in girls. 
Convulsions are not uncommon, and in fits developing in the adult the 
possibility of lead-poisoning should always be considered. True epilepsy 
may follow the convulsions. An acute delirium may occur with hallucina- 
tions. The patients may have trance-like attacks, which follow or alternate 
with convulsions. A few cases of lead encephalopathy finally drift into 
lunatic asylums. Tremor is one of the commonest manifestations of lead- 
poisoning. 

(/) Arteriosclerosis. — Lead-workers are notoriously subject to arterio- 
sclerosis with contracted kidneys and hypertrophy of the heart. The cases 
usually show distinct gouty deposits, particularly in the big-toe joint; but 
in this country acute gout in lead-workers is rare. According to Sir Wil- 
liam Eoberts, the lead favors the precipitation of the crystalline urates of 
the tissues. Ralfe has shown that lead diminishes the alkalinity of the 
"blood, and so lessens the solubility of the uric acid. 

Prognosis. — In the minor manifestations of lead-poisoning this is 
good. According to Gowers, the outlook is bad in the primary atrophic 
form of paralysis. Convulsions are, as a rule, serious, and the mental 
symptoms which succeed may be permanent. Occasionally the wrist-drop 
persists. 

Treatment. — Prophylactic measures should be taken at all lead-works, 
but, unless employes are careful, poisoning is apt to occur even under the 
most favorable conditions. Cleanliness of the hands and of the finger-nails, 
frequenl bathing, and the use of respirators when necessary, should be in- 
sisted upon. When the lead is in the system, the iodide of potassium 
should be given in from 5- to 10-grain doses three times a day. For the 
colic, local applications and, if severe, morphia may be used. An occa- 
sional morning purge of magnesium sulphate may be given. For the anae- 
mia iron should be used. In the very acute cases it is well not to srive the 
iodide, as, according to some writers, the liberation of the lead which has 
been deposited in the tissues may increase the severity of the symptoms. 
For the local palsies massage and the constant current should be used. 



390 



THE INTOXICATIONS AND SDN-STROKE. 



IV. ARSENICAL POISONING. 

Acute poisoning by arsenic is common, particularly by Paris green and 
such mixtures as " Eougli on Rats," which are used to destroy vermin and 
insects. The chief symptoms are intense pain in the stomach, vomiting,, 
and, later, colic, with diarrhoea and tenesmus; occasionally the symptoms 
are those of collapse. If recovery takes place, paralysis may follow. The 
treatment should be similar to that of other irritant poisons — rapid re- 
moval with the stomach pump, the promotion of vomiting, and the use 
of milk and eggs. If the poison has been taken in solution, dialyzed iron 
may be used in doses of from 6 to 8 drachms. 

Chronic Arsenical Poisoning. — Arsenic is used extensively in the arts,, 
particularly in the manufacture of colored papers, artificial flowers, and 
in many of the fabrics employed as clothing. The glazed green and red 
papers used in kindergartens also contain arsenic. It is present, too, in 
many wall-papers and carpets. Much attention has been paid to this ques- 
tion of late years, as instances of poisoning have been thought to depend 
upon wall-papers and other household fabrics. The arsenic compounds 
may be either in the form of solid particles detached from the paper or as 
gaseous volatile bodies formed from arsenical organic matter by the action 
of several moulds, notably penicilium brevicaule, mucor mucedo, etc. 
(Gosio). In moisture, and at a temperature of from 60° to 95° F., a vola- 
tile compound is set free, probably " an organic derivative of arsenic pen- 
toxide " (Sanger). The chronic poisoning from fabrics and wall-papers 
may be due, according to this author, to the ingestion of minute continued 
doses of this derivative. Contaminated glucose, used in manufacturing 
beer, caused the recent epidemic of poisoning at Manchester. The asso- 
ciated presence of selenium compounds may have played a part in the pro- 
duction of the poisoning (Tunnicliffe and Eosenheim). Arsenic is elimi- 
nated in all the secretions, and has been found in the milk. J. J. Putnam, 
it should be remembered, has shown that it is not uncommon to find traces 
of arsenic in the urine of many persons in apparent health (30 per cent). 
The effects of moderate quantities of arsenic are not infrequently seen in 
medical practice. In chorea and in pernicious anaemia, steadily increasing 
doses are often given until the patient takes from 15 to 20 drops of Fowler's 
solution three times a day. Flushing and hyperemia of the skin, puffiness 
of the eyelids or above the eyebrows, nausea, vomiting, and diarrhoea are 
the most common symptoms. Eedness and sometimes bleeding of the gums 
and salivation occur. In the protracted administration of arsenic patients 
may complain of numbness and tingling in the fingers. Cutaneous pig- 
mentation and keratosis are very characteristic. In chorea neuritis has 
occurred, and a patient of mine with Hodgkin's disease developed multiple 
neuritis after taking §iv oj of Fowler's solution in seventy-five days, dur- 
ing which time there were fourteen days on which the drug was omitted. 

In the Manchester epidemic nearly all cases presented signs of neuritis 
and lesions of the skin. In some the sensory disturbances predominated, 
in others the motor, the individuals being unable to walk or to use their 



FOOD POISONING. 



391 



hands. In a certain number muscular inco-ordination, resembling that of 
locomotor ataxia, developed. Eapid muscular atrophy characterized some 
cases. In not a few patients a condition of erythromelalgia was present. 
Occasionally a catarrh of the respiratory and alimentary tracts was the 
chief feature. Pigmentation, keratosis, and herpes were the most charac- 
teristic cutaneous manifestations (Kelynack and Kirkby, Arsenical Poison- 
ing in Beer Drinkers). How far similar symptoms are to be attributed to 
the small quantities of arsenic absorbed from wall-papers and fabrics is by 
some considered doubtful. That children and adults may take with im- 
punity large doses for months without unpleasant effects, and the fact of 
the gradual establishment of a toleration which enables Styrian peasants 
to take as much as 8 grains of arsenious acid in a day, speak strongly 
-against it. On the other hand, as Sanger states, we do not know accurately 
the effects of many of the compounds in minute and long-continued doses, 
notably the arsenates. 

Arsenical paralysis has the same characteristics as lead-palsy, but the 
legs are more affected than the arms, particularly the extensors and pero- 
neal group, so that the patient has the characteristic steppage gait of 
peripheral neuritis. 

The electrical reaction in the muscles may be disturbed before there is 
any loss of power, and when the patient is asked to extend the wrist fully 
and to spread the fingers slight weakness may be detected early. 



V. FOOD POISONING. (Bromatotoxismus : Vaughan). 

There may be " death in the pot " from many causes. Food may con- 
tain the specific organisms of disease, as of tuberculosis or trichinosis; milk 
and other foods may become infected with typhoid bacilli, and so convey 
the disease. 

Animals (or insects, as bees) may feed on substances which cause their 
flesh or products to be poisonous to man. 

The grains used as food may be infected with fungi and cause the epi- 
demics of ergotism, etc. 

Foods of all sorts may become contaminated with the bacteria of putre- 
faction, the products of which may be highly poisonous. 

For a full description of food poisoning see Vaughan's section on the 
subject in vol. xiii of the Twentieth Century Practice. 

Among the more common forms are the following: 

(1) Meat Poisoning (Kreotoxismus). — Cases have usually followed the 
eating of sausages or pork-pie or head-cheese, and also occasionally beef, veal, 
and mutton. Sausage poisoning, which is known by the name of botulism 
or allantiasis, has long been recognized, and there have been numerous 
outbreaks, particularly in parts of Germany. Similar attacks have been 
produced by ham and by head-cheese. The precise nature of the kreotoxi- 
cons has not yet been determined. Other outbreaks have followed the 
eating of beef and veal. In the majority of these cases the meat has under- 
gone decomposition, though the change may not have been evident to the 



392 



THE INTOXICATIONS AND SUN-STROKE. 



taste. The symptoms of meat poisoning are those of acute gastro-intestinal 
irritation. BallarcPs description of the Wellbeck eases, quoted by Vaughan, 
holds good for a majority of them: 

" A period of incubation preceded the illness. In 51 cases where this 
could be accurately determined, it was twelve hours or less in 5 cases; be- 
tween twelve and thirty-six hours in 34 cases; between thirty-six and 
forty-eight hours in 8 cases; and later than this in only 4 cases. In many 
cases the first definite symptoms occurred suddenly, and evidently unex- 
pectedly, but in some cases there were observed during the incubation 
more or less feeling of languor and ill-health, loss of appetite, nausea, or 
fugitive, griping pains in the belly. In about a third of the cases the first 
definite symptom was a sense of chilliness, usually with rigors, or trem- 
bling, in one case accompanied by dyspnoea; in a few cases it was giddi- 
ness with faintness, sometimes accompanied by a cold sweat and tottering; 
in others the first symptom was headache or pain somewhere in the trunk 
of the body — e. g., in the chest, back, between the shoulders, or in the ab- 
domen, to which part the pain, wherever it might have commenced, subse- 
quently extended. In one ease the first symptom noticed was a difficulty 
in swallowing. In two cases it was intense thirst. But however the attack 
may have commenced, it was usually not long before pain in the abdomen, 
diarrhoea, and vomiting came on, diarrhoea being of more certain occur- 
rence than vomiting. The pain in several cases commenced in the chest 
or between the shoulders, and extended first to the upper and then to the 
lower part of the abdomen. It was usually very severe indeed, quickly 
producing prostration or faintness, with cold sweats. It was variously de- 
scribed as crampy, burning, tearing, etc. The diarrhoeal discharges were 
in some cases quite unrestrainable, and (where a description of them could 
be obtained) were said to have been exceedingly offensive and usually of a 
dark color. Muscular weakness was an early and very remarkable symp- 
tom in nearly all the cases, and in many it was so great that the patient 
could only stand by holding on to something. Headache, sometimes severe, 
was a common and early symptom; and in most cases there was thirst, often 
intense and most distressing. The tongue, when observed, was described 
usually as thickly coated with a brown, velvety fur, but red at the tip and 
edges. In the early stage the skin was often cold to the touch, but after- 
ward fever set in, the temperature rising in some cases to 101°, 103°, and 
104° F. In a few severe cases, where the skin was actually cold, the patient 
complained of heat, insisted on throwing off the bedclothes, and was very 
restless. The pulse in the height of the illness became quick, counting 
in some cases 100 to 128. The above were the symptoms most frequently 
noted. Other symptoms occurred, however, some in a few cases, and some 
only in solitary cases. These I now proceed to enumerate. Excessive 
sweating, cramps in the legs, or in both legs and arms, convulsive flexion 
of the hands or fingers, muscular twitchings of the face, shoulders, or 
hands, aching pain in the shoulders, joints, or extremities, a sense of stiff- 
ness of the joints, prickling or tingling or numbness of the hands lasting 
far into convalescence in some cases, a sense of general compression of the 
skin, drowsiness, hallucinations, imperfection of vision, and intolerance 



FOOD POISONING. 



393 



of light. In three cases (one that of a medical man) there was observed 
yellowness of the skin, either general or confined to the face and eyes. In 
one case, at a late stage of the illness, there was some pulmonary congestion 
and an attack of what was regarded as gout. In the fatal cases death waa 
preceded by collapse like that of cholera, coldness of the surface, pinched 
features, and blueness of the fingers and toes and around the sunken eyes. 
The debility of convalescence was in nearly all cases protracted to several 
weeks. 

" The mildest cases were characterized usually by little remarkable be- 
yond the following symptoms, viz., abdominal pains, vomiting, diarrhoea, 
thirst, headache, and muscular weakness, any one or two of which might 
be absent." 

Many instances are on record of poisoning by canned goods, particu- 
larly meat. Some of these, according to John G-. Johnson, have been cases, 
of corrosive poisoning from muriate of zinc and muriate of tin used as an 
amalgam, but poisonous effects identical with those just described have 
followed the use of canned meats. 

Certain game birds, particularly the grouse, are stated to be poisonous, 
in special districts and at certain seasons of the year. 

(2) Poisoning by Milk Products. — (a) Galactotoxismus, indicating the 
poisonous effects which follow the drinking of milk infected with sapro- 
phytic bacteria, is considered in the section on the diarrhoea of infants. 

(b) Cheese Poisoning (Tyrotoxismus). — Various milk products, ice cream,, 
custard, and cheese may prove highly poisonous. Among the poisons 
Yaughan now states that the tyrotoxicon " is not the one most frequently 
present, nor is it the most active one." In one epidemic he and Novy have 
isolated from cheese a substance belonging to the poisonous albumins, 
and in an extensive ice-cream epidemic Vaughan and Perkins found 
in the ice cream a highly pathogenic bacillus, but its toxine has not been 
separated. 

The symptoms are those of acute gastro-intestinal irritation, and are 
similar to those already detailed by Ballard. 

(3) Poisoning by Shell-fish and Fish. — (a) Mussel Poisoning (Mytilo- 
toxismus). — Brieger has separated a ptomaine — mytilotoxin — which exists 
chiefly in the liver of the mussel. The observations of Schmidtmann and 
Cameron have shown that the mussel from the open sea only becomes 
poisonous when placed in filthy waters, as at Wilhelmshafen. 

Dangerous, even fatal, effects may follow the eating of either raw or 
cooked mussels. The symptoms are those of an acute poisoning with pro- 
found action on the nervous system, and without gastro-intestinal manifes- 
tations. There are numbness and coldness, no fever, dilated pupils, and 
rapid pulse; death occurs sometimes within two hours with collapse symp- 
toms. Poisoning occasionally follows the eating of oysters which are stale 
or decomposed. The symptoms are usually gastro-intestinal. 

(h) Fish Poisoning (Ichthyotoxismus). — There are two distinct varie- 
ties; in one the poison is a physiological product of certain glands of the 
fish, in the other it is a product of bacterial growth. The salted sturgeon 
used in parts of Russia has sometimes proved fatal to large numbers of 



394 



THE INTOXICATIONS AND SUN-STROKE. 



persons. In the middle parts of Europe the barb is stated to be sometimes 
poisonous, producing the so-called "harden cholera." In China and Japan 
various species of the tetrodon are also toxic, sometimes causing death within 
.an hour, with symptoms of intense disturbance of the nervous system. 
Beri-beri is thought by some to be due to the consumption of certain kinds 
■of fish. 

(4) Grain Poisoning (SUotoxismus). 

(1) Ergotism. — The prolonged use of meal made from grains contam- 
inated with the ergot fungus (claviceps purpurea) causes a series of symp- 
toms known as ergotism, epidemics of which have prevailed in different 
parts of Europe. Two forms of this chronic ergotism are described — the 
one, gangrenous, is believed to be due to the sphacelinic acid, the other, 
convulsive, or spasmodic, is due to the cornutin. In the former, mortifica- 
tion affects the extremities — usually the toes and fingers, less commonly 
the ears and nose. Preceding the onset of the gangrene there are usually 
anaesthesia, tingling, pains, spasmodic movements of the muscles, and grad- 
ual blood stasis in certain vascular territories. 

The nervous manifestations are very remarkable. After a prodromal 
stage of ten to fourteen days, in which the patient complains of weakness, 
headache, and tingling sensations in different parts of the body, perhaps 
•accompanied with slight fever, symptoms of spasm develop, producing 
cramps in the muscles and contractures. The arms are flexed and the 
legs and toes extended. These spasms may last from a few hours to many 
days and relapses are frequent. In severer cases epilepsy develops and the 
patient may die in convulsions. Mental symptoms are common, manifested 
sometimes in a preliminary delirium, but more commonly, in the chronic 
poisoning, as melancholia or dementia. Posterior spinal sclerosis occurs 
in chronic ergotism. In the interesting group of 29 cases studied by 
Tuczek and Siemens, 9 died at various periods after the infection, and 
four post mortems showed degeneration of the posterior columns. A con- 
dition similar to tabes dorsalis is gradually produced by this slow degenera- 
tion in the spinal cord. 

(2) Latkyrism (Lupinosis). — An affection produced by the use of meal 
from varieties of vetches, chiefly the Lathyrus sativus and L. cicera. The 
grain is popularly known as the chkk-pea. The grains are usually pow- 
dered and mixed with the meal from other cereals in the preparation of 
bread. . As early as the seventeenth century it was noticed that the use 
of flour with which the seeds of the Lathyrus were mixed caused stiffness 
of the legs. The subject did not, however, attract much attention before 
the studies of James Irving, in India, who between 1859 and 1868 pub- 
lished several important communications, describing a form of spastic 
paraplegia affecting large numbers of the inhabitants in certain regions of 
India and due to the use of meal made from the Lathyrus seeds. It also 
produces a spastic paraplegia in animals. The Italian observers describe 
a similar form of paraplegia, and it has been observed in Algiers by the 
Trench physicians. The condition is that of a spastic paralysis, involving 
chiefly the legs, which may proceed to complete paraplegia. The arms 
;are rarely, if ever, affected. It is evidently a slow sclerosis induced under 



SUN-STROKE. 



395 



the influence of this toxic agent. The precise anatomical condition, so 
far as I can ascertain, has not yet been determined. 

(3) Pellagra (Maidismus). — This is a nutritional disturbance due to 
the use of altered maize. The disease occurs extensively in parts of Italy, 
in the south of France, and in Spain. It has not been observed in this 
country. It prevails extensively among the poorer classes, particularly in 
the country districts, and appears to be associated in some way with the 
use of maize which (according to most authorities) is fermented or diseased. 
In the early stage the symptoms are indefinite, characterized by debility, 
pains in the spine, insomnia, digestive disturbances, more rarely diarrhoea. 
The first clear manifestation of the disease is the pellagral erythema, which 
almost invariably appears in the spring. This is followed by desiccation 
and exfoliation of the epidermis, which becomes very rough and dry, and 
occasionally crusts form, beneath which there is suppuration. With these 
cutaneous manifestations there are digestive troubles — salivation, dyspepsia, 
and diarrhoea — which may be of a dysenteric nature. After lasting for a 
few months improvement occurs in the milder cases and convalescence is 
gradually established. In the more severe and chronic forms there are 
pronounced nervous symptoms — headache, backache, spasms, and finally 
paralysis and mental disturbance. The paralytic condition affects the legs 
and leads gradually to paraplegia. The mental manifestations, which 
are rarely met with until the third or fourth attack, are melancholia or 
suicidal mania. Finally, there may be a condition of the most pronounced 
cachexia. 

The anatomical findings are indefinite. Chronic degenerative changes 
have been found, particularly fatty degeneration and a peculiar pigmenta- 
tion in the viscera. The measures to be employed are change in diet, re- 
moval from the infected district, and, as a prophylaxis, proper preserva- 
tion of the maize. 

VI. SUN-STROKE (Siriasis). 
(Heat Exhaustion ; Insolation ; Thermic Fever ; Heat-stroke ; Coup de Soleil.) 

Definition. — A condition produced by exposure to excessive heat. 

It is one of the oldest of recognized diseases; two instances are men- 
tioned in the Bible. It was long confounded with apoplexy. The Anglo- 
Indian surgeons gave admirable descriptions of it. In this country the 
most important contributions have come from the New York Hospital and 
the Pennsylvania Hospital; from the former, the studies of Swift and 
Darrach, from the latter, the papers of Gerhard, George B. Wood, the 
elder Pepper, and Levick. In New Orleans, Bennett Dowler studied the 
disease and recognized the difference between heat exhaustion and sun- 
stroke. Two forms are recognized, heat exhaustion and heat-stroke. 

Heat Exhaustion. — Prolonged exposure to high temperatures, particu- 
larly when combined with physical exertion, is liable to bo followed by 
extreme prostration, collapse, restlessness, and in severe eases by delirium. 
The surface is usually cool, the pulse small and rapid, and the temperature 
may be subnormal — as low as 95° or 96°. The individual need not neces- 
25 



396 



THE INTOXICATIONS AND SUN-STROKE. 



sarily be exposed to the direct rays of the sun, but the condition may- 
come on at night or when working in close, confined rooms. It may also- 
follow exposure to great artificial heat, as in the engine rooms of the Atlan- 
tic steamships. 

Sun-stroke or Thermic Fever. — The cases are chiefly found in persons- 
who, while working very hard, are exposed to the sun. Soldiers on the 
march with their heavy accoutrements are particularly liable to attack.. 
In the larger cities of this country the cases are almost exclusively con- 
fined to workmen who are much exposed and, at the same time, have been 
drinking beer and whisky. 

Morbid Anatomy and Pathology. — Rigor mortis occurs early. 
Putrefactive changes develop with great rapidity. The venous engorge- 
ment is extreme, particularly in the cerebrum. The left ventricle is con- 
tracted (Wood), and the right chamber dilated. The blood is usually fluid; 
the lungs are intensely congested. Parenchymatous changes occur in the 
liver and kidneys. 

According to Wood, " heat exhaustion with lowered temperature repre- 
sents a sudden vaso-motor palsy, i. e., a condition in which the existing 
effect of the heat paralyzes the centre in the medulla." On the other hand,, 
thermic fever is held to be due to paralysis under the influence of the ex- 
treme external heat of the centre in the medulla which regulates the dis- 
position of the bodily heat. Owing to this disturbance, more heat is pro- 
duced and less given off than normally. 

Sambron has recently (B. M. J., 1898, i) advanced the view that siriasis- 
is an infectious disease. He argues that heat alone cannot cause it, that 
it occurs in certain localities and in epidemic outbursts, and persons ac- 
climatized have a relative immunity, etc. The question is one worthy of 
most careful study. 

Symptoms. — The patient may be struck down and die within an' 
hour with symptoms of heart-failure, dyspnoea, and coma. This form;, 
sometimes known as the asphyxial, occurs chiefly in soldiers and is graphic- 
ally described by Parkes. Death indeed may be almost instantaneous, the 
victims falling as if struck upon the head. The usual form in this lati- 
tude comes on during exposure, with pain in the head, dizziness, a feel- 
ing of oppression, and sometimes nausea and vomiting. Visual disturb- 
ances are common, and a patient may have colored vision. Diarrhoea or 
frequent micturition may supervene. Insensibility follows, which may 
be transient or which deepens into a profound coma. The patients are 
usually admitted to hospital in an unconscious state, with the face flushed, 
the skin pungent, the pulse rapid and full, and the temperature ranging- 
from 107° to 110°, or even higher, as shown in the accompanying chart. 
F. A. Packard states that of the 31 cases admitted to the Pennsylvania- 
Hospital in the summer of 1887, in a majority of them the temperature 
was between 110° and 111 0 . In one case the temperature was 112°. The 
breathing is labored and deep, sometimes stertorous. Usually there is 
complete relaxation of the muscles, but twitchings, jactitation, or very 
rarely convulsions may occur. The pupils may at first be dilated, but by 
the time the cases are admitted to hospital they are (in a majority) ex- 



SUN-STROKE. 



397 



tremely contracted. Petechia? may be present upon the skin. In the fatal 
cases the coma deepens, the cardiac pulsations become more rapid and 
feeble, the breathing becomes hurried and shallow and of the Cheyne- 
Stokes type. The fatal termination may occur within twenty-four or 
thirty-six hours. Favorable indications are the return of consciousness 
and a fall in the fever. The recovery in these cases may be complete. In 
other instances there are remarkable after-effects, the most constant of which 
is a permanent inability to bear high temperatures. Such patients become 
very uneasy when the thermometer reaches 80° F. in the shade. Loss of 
the power of mental concentration and failure of memory are more con- 
stant and very troublesome sequela?. Such patients are always worse in the 



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Chart XIII. — Case of sun-stroke treated with the ice-bath ; recovery. 
(Rectal temperatures). 



hot weather. Occasionally convulsions and marked mental disturbance 
may develop. Dercum has described peripheral neuritis as a sequence, and 
the patient whose chart is here given developed an acute neuritis in 
the legs. This is a point in favor of the infectious nature of the dis- 
ease. 

GuitSras lias called attention to a form of fever occurring in the South, 
known in Florida as " Florida fever," in the Carolinas as " country fever," 
and in tropical countries as fievre inflammatoirc. The cases last for a vari- 
able time, and are mistaken for malaria or typhoid; but he believes them 



398 



THE INTOXICATIONS AND SUN-STROKE. 



to be entirely distinct and due to a prolonged action of the high tempera- 
tures. He has called the condition a " continued thermic fever." 

The diagnosis of heat exhaustion from thermic fever is readily made, 
as the difference between the two conditions is striking. " In solar ex- 
haustion the skin is moist, pale, and cool; the breathing is easy though 
hurried; the pulse is small and soft; the vital forces fall into a temporary 
collapse; the senses remain entire " (Dowler); whereas in sun-stroke or 
heat apoplexy there is usually unconsciousness and pyrexia. 

The mode of onset, together with the circumstances under which it 
occurs and the high temperature, permits thermic fever to be readily dif- 
ferentiated from apoplexy and coma from other conditions. 

Treatment. — In heat exhaustion stimulants should be given freely, 
and if the temperature is below normal the hot bath should be used. 
Ammonia may be given if necessary. In thermic fever the indications 
are to reduce the temperature as rapidly as possible. This may be done 
by packing the patient in a bath with ice. Eubbing the body with ice was 
practised at the New York Hospital by Darrach in 1857, and is an excel- 
lent procedure to lower the temperature rapidly. Ice-water enemata may 
also be employed. At the Pennsylvania Hospital in the summer of 1887 
♦ the ice-pack was used with great advantage. Of 31 cases only 12 died, 
results probably as satisfactory as can be obtained, considering that many 
of the patients are almost moribund when brought to hospital. They should 
be compared with Swift's statistics, in which of 150 cases 78 died. In the 
cases in which the symptoms are those of intense asphyxia, and in which 
death may take place in a few minutes, free bleeding should be practised, 
a procedure which saved Weir Mitchell when a young man. For the con- 
vulsions chloroform should be given at once. Of other remedies, the anti- 
pyretics have been employed, and may be given when there is any special 
objection to hydrotherapy, for which, however, they cannot be substituted. 



SECTION IV. 
CONSTITUTIONAL DISEASES. 

I. ARTHRITIS DEFORMANS. 

Definition. — A chronic disease of the joints of doubtful etiology, 
characterized by changes in the cartilages and synovial membranes, with 
peri-articular formation of bone and great deformity. 

Long believed to be intimately associated with gout and rheumatism 
(whence the names rheumatic gout and rheumatoid arthritis), this close 
relationship seems now very doubtful, since in a majority of the cases no 
history of either affection can be determined. 

Etiology. — Age. — A majority of the cases are between the ages of 
thirty and fifty. In A. E. Garrod's analysis of 500 cases there were only 25 
under twenty years of age. 

Sex. — Among Garrod's 500 cases there were 411 in women. In James 
Stewart's recent report of 40 cases from the Eoyal Victoria Hospital only 
20 were in females. In women its close association with the menopause 
has been noted. It seems to be more frequent, too, in those who have had 
ovarian or uterine trouble or who are sterile. 

Hereditary Predisposition. — In 216 cases in Garrod's series there was a 
family history of joint troubles. Two or three children in a family may 
be affected. It is stated also that the disease is more common in families 
with a phthisical history. 

Rheumatism and Gout. — In nearly a third of Garrod's cases there was 
a history of gout in the family; of rheumatism in only 64 cases. 

Exposure to cold, wet and damp, errors in diet, worry and care, and 
local injuries are all spoken of as possible exciting causes. 

At present there are two chief views prevailing as to the etiology of 
arthritis deformans — one that it is of nervous origin, the other that it is a 
chronic infection. 

The Relation of Arthritis Deformans to Diseases of the Nervous Sys- 
tem. — Our accurate knowledge of arthropathies of nervous origin dates 
from the papers of J. K. Mitchell, of Philadelphia, in 1831 and 1833, in 
which ho reported cases of inflammation of the joints in connection with 
caries of the spine and concussion of the cord. Acute and chronic forms 
of arthritis may occur with gross lesions of the cord; the former are found 

809 



400 



CONSTITUTIONAL DISEASES. 



in acute myelitis, the latter with tabes and syringomyelia. The acute 
spinal arthritis presents anatomically inflammation of the synovial sheaths 
and of the fibrous investment of the articulations. The chronic arthritis 
which we see in syringomyelia, tabes, and hemiplegia presents a combination 
of atrophy and hyperplasia of the bones, with thickening of the liga- 
ments and more or less effusion. Again, there are joint lesions which 
follow injuries of the nerve trunks themselves, cases of which have been 
reported by S. Weir Mitchell. The following are the main points urged in 
favor of the nervous origin of the disease: First, the articular changes are 
similar to, if not identical with, those of the chronic spinal arthrop- 
athies. Secondly, the frequent association in arthritis deformans of dys- 
trophies of the skin (glossy skin), nails, bones, and muscles — changes which 
are evidently of neurotic origin. In certain cases there is marked and early 
atrophy of the muscles. Ord, indeed, thinks that this atrophy with the 
articular lesions forms a dystrophy analogous to progressive muscular atro- 
phy. Thirdly, the symmetrical onset and progress of the disease. Fourthly, 
the implication of nerve trunks. There may be not only numbness and 
tingling, but in certain cases excruciating pains. Post mortem, neuritis 
has been found in several cases, but whether primary or secondary is doubt- 
ful. The reflexes are not infrequently increased, in 32 of 50 of Garrod's 
cases. We need information as to the condition of the spinal cord in these 
cases of arthritis deformans. Triboulet and Thomas have reported from 
Dejerine's service a case of a woman with chronic arthritis, in whom the 
autopsy showed a sclerosis of the posterior columns of the cord in the dorsal 
region and of the columns of Goll in the cervical region, with degeneration 
of the posterior roots. The history indicated that the arthritis developed 
after a puerperal infection. 

Arthritis Deformans as a Chronic Infection. — During the past few 
years the idea has been gaining ground that the disease is of microbic origin. 
Satisfactory evidence for this view is not yet forthcoming. Schuller, Ban- 
natyne and Blaxall, and several French observers have found micro-organ- 
isms in the fluid of the joints. More valuable really is the frequent asso- 
ciation of arthritis deformans with previous acute infections; thus in James 
Stewart's cases there was a history of gonorrhoea in 30 per cent of the males, 
and in his series of 40 cases 50 per cent had had previously some infectious 
trouble. Of late years we have learned to recognize cases which have fol- 
lowed directly upon a severe attack of influenza. 

The acute mode of onset in some instances is suggestive of an infection. 
The joints may be red and swollen and painful, and present the clinical 
picture of an acute infective process. 

And, lastly, a consideration of the form in children described by Still 
lends weight to this view, particularly in the widespread enlargement of 
the lymph-glands and the swelling of the spleen. A number of the very 
best students of the disease, as Baumler, of Freiburg, have accepted the 
infective theory of origin, which is gaining adherents, though it still 
lacks demonstration. 

Morbid Anatomy. — The changes in the joints differ essentially 
from those of gout in the absence of deposits of urate of soda, and from 



ARTHRITIS DEFORMANS. 



401 



/chronic rheumatism in the existence of extensive structural alterations, 
particularly in the cartilages. We are largely indebted to the magnificent 
work of Adams for our knowledge of the anatomy of this disease. The 
changes begin in the cartilages and synovial membranes, the cells of which 
proliferate. The cartilage covering the joint undergoes a peculiar fibrilla- 
tion, becomes soft, and is either absorbed or gradually thinned by attri- 
tion, thus laying bare the ends of the bone, which become smooth, polished, 
.and eburnated. At the margins, where the pressure is less, the proliferating 
•elements may develop into irregular nodules, which ossify and enlarge the 
heads of the bones, forming osteophytes which completely lock the joint. 
The periosteum may also form new bone. There is usually great thicken- 
ing of the ligaments, and finally complete anchylosis results. This is rarely, 
however, a true anchylosis, but is caused by the osteophytes and thickened 
ligaments. There are often hyperostosis and increase in the articular ends 
• of the bone in length and thickness. In long-standing cases and in old 
persons there may, on the other hand, be great atrophy of the heads of the 
•affected bones. The spongy substance becomes friable, and in the hip- joint 
the wasting may reach such an extreme grade that the articulating surface 
lies between the trochanters. This is sometimes called morbus coxce senilis. 
The anatomical changes may lead to great deformity. The metacarpal 
joints are enlarged and thickened, and the fingers are deflected toward the 
.ulnar side. The toes often show a similar deflection. The exostoses at the 
joints are known as Haygarth/s nodosities. 

The radiographs of arthritis deformans are very instructive. The clear 
interosseous spaces at the level of the joints disappear early, the hyper- 
trophy and deformity of the articular extremities, and more particularly 
the exostoses at the margins, give a very distinctive picture of the dis- 
ease. 

The muscles become atrophied, and in some cases the wasting reaches 
a high grade. Neuritis has been demonstrated in the nerves about the 
joints. 

Symptoms. — For convenience the forms may be described as those 
with Heberden's nodes, general progressive arthritis, the mono-articular 
form, the vertebral form, and the arthritis deformans of children. 

Heberden's Nodes, — In this form the fingers are affected, and " little 
hard knobs " develop gradually at the sides of the distal phalanges. They 
are much more common in women than in men. They begin usually be- 
1 ween the thirtieth and fortieth year. The subjects may have had digestive 
troubles or gout. Heberden, however, says " they have no connection with 
gout, being found in persons who never had it." In the early stage the 
joints may be swollen, tender, and slightly red, particularly when knocked. 
The attacks of pain and swelling may come on in the joints at long inter- 
vals or follow indiscretion in diet. The little tubercles at the sides of the 
dorsal surface of the second phalanx increase in size, and give the charac- 
teristic appearance to the affection. The cartilages also become soft, 
and (lie ends of the bones eburnated. Urate of soda is never deposited 
(Charcot). The condition is not curable; but there is this hopeful 
feature — the subjects of these nodosities rarely have involvement of the 



402 



CONSTITUTIONAL DISEASES. 



larger joints. They have been regarded, too, as an indication of longevity. 
Charcot states that in women with these nodes cancer seems more fre- 
quent. 

General Progressive Form. — This occurs in two varieties, acute and 
chronic. The acute form may resemble, at its outset, ordinary articular 
rheumatism. There is involvement of many joints; swelling, particularly 
of the synovial sheaths and bursse; not often redness; but there is mod- 
erate fever. Howard describes this condition as most frequent in young 
women from twenty to thirty years of age, often in connection with recent 
delivery, lactation, or rapid child-bearing. Acute cases may develop at 
the menopause. It may also come on in children. " These patients sutler 
in their general health, become weak, pale, depressed in spirits, and lose 
flesh. In several cases of this form marked intervals of improvement have 
occurred; the local disease has ceased to progress, and tolerable comfort 
has been experienced perhaps until pregnancy, delivery, or lactation again 
determines a fresh outbreak of the disease." 

The chronic form is by far the most common. The joints are usually 
involved symmetrically. The first symptoms are pain on movement and 
slight swelling, which may be in the joint itself or in the peri-articular 
sheaths. In some cases the effusion is marked, in others slight. The local 
conditions vary greatly, and periods of improvement alternate with attacks 
of swelling, redness, and pain. At first only one or two joints are affected; 
usually the joints of the hands, then the knees and feet; gradually other 
articulations are involved, and in extreme cases every joint in the body 
is affected. Pain is an extremely variable symptom. Some cases pro- 
ceed to the most extreme deformity without it; in others the suffering is 
very great, particularly at night and during exacerbations of the disease. 
There are cases in which pain of an agonizing character is an almost con- 
stant symptom, requiring for years the use of morphia. 

Gradually the shape of the joints is greatly altered, partly by the pres- 
ence of osteophytes, partly by the great thickening of the capsular liga- 
ments, and still more by the retraction of the muscles. In moving the 
affected joint crepitation can be felt, due to the eburnation of the articular 
surfaces. Ultimately the joints become completely locked, not by a true 
bony anchylosis, but by the osteophytes which form around the articular 
surfaces, like ring-bone in horses. There is also a spurious anchylosis, 
caused by the thickening of the capsular ligaments and fibrous adhesions. 
The muscles about the joints undergo important changes. Atrophy from 
disuse gradually supervenes, and contractures tend to flex the thigh upon 
the abdomen and the leg upon the thigh. There are cases with rapid 
muscular wasting, symmetrical involvement of the joints, increased reflexes, 
and trophic changes, which strongly suggest a central origin. Numbness, 
tingling, pigmentation or glossiness of the skin, and onychia may be pres- 
ent. In extreme cases the patient is completely helpless, and lies on one 
side with the legs drawn up, the arms fixed, and all the articulations of the 
extremities locked. Fortunately, it often happens in these severe general 
cases that the joints of the hand are not so much affected, and the patient 
may be able to knit or to write, though unable to walk or to use the arms. 



ARTHRITIS DEFORMANS. 



403 



In many cases, after involving two or three joints, the disease becomes ar- 
rested, and no further development occurs. It may be limited to the 
wrists, or to the knees and wrists, or to the knees and ankles. A majority 
of the patients finally reach a quiescent stage, in which they are free from 
pain and enjoy excellent health, suffering only from the inconvenience 
and crippling necessarily associated with the disease. Coincident affec- 
tions are not uncommon. In the active stage the patients are often anaemic 
and suffer from dyspepsia, which may recur at intervals. There is no tend- 
ency to involvement of the heart. 

The partial or mono-articular form affects chiefly old persons, and is 
seen particularly in the hip, the knee, the spinal column, or shoulder. It 
is, in its anatomical features, identical with the general disease. In the 
hip and shoulder the muscles early show wasting, and in the hip the con- 
dition ultimately becomes that already described as morbus coxce senilis. 
These cases seem not infrequently to follow an injury. They differ from the 
polyarticular form in occurring chiefly in men and at a later period of life. 

The Vertebral Form. — There is a progressive anchylosis of the verte- 
brae, causing rigidity of the spine — " poker-back " — spondylitis deformans. 
There are two varieties. In one (von Bechterew), in which the disease may 
follow trauma or be hereditary, the spine alone is involved, and there are 
pronounced nerve-root symptoms — pain, anaesthesia, atrophy of muscles, and 
ascending degeneration in the cord; in the other — Striimpell-Marie type — 
the hip and shoulder joints may be involved (spondylose rhizomelique) , and 
the nervous symptoms are less prominent. I believe they are both forms 
of arthritis deformans, and should neither be regarded nor described as 
separate diseases. The cases are more frequent in males than in females; 
the onset may be in the upper or in the lower part of the spine. It may 
be limited to the neck. There is gradually induced complete immobility, 
with some kyphosis. The other joints may not be affected, or the hips and 
shoulders may be anchylosed. The ribs are fixed, the thorax immobile, 
and the breathing abdominal. Pressure on the nerve-roots may cause great 
pain, paraesthesia, and atrophy of muscles. Von Bechterew thinks that 
the disease begins as a meningitis, leads to compression of the nerve-roots, 
loss of function of the spinal muscles, atrophy of the intervertebral disks, 
and gradually anchylosis of the spines. Seguin reported three children in 
one family. 

Arthritis Deformans in Children. — Some examples certainly resemble 
closely the disease in adults. In others there are very striking differences. 
A very interesting variety has been differentiated by George F. Still, in 
which the general enlargement of the joints is associated with swelling of 
the lymph-glands and of the spleen. He has studied 22 cases of this char- 
acter. The following are among the more striking peculiarities: The 
onset is almost' always before the second dentition. Girls are more fre- 
quently affected than boys. The symptoms complained of are usually slight 
stiffness in one or two joints; gradually others become involved. The onset 
may be more acute; with fever, or even with chills. The enlargement of 
the joints is due rather to a general thickening of the soft tissues than to 
a bony enlargement. There is no bony grating. The limitation of move- 



404 



CONSTITUTIONAL DISEASES. 



ment may be extreme, owing to the fixation of the joints, and there may 
be much muscular wasting. The enlargement of the lymph-glands is most 
striking, and may be general; even the supratrochlear glands may be as 
large as hazel-nuts. They increase with the fever. The edge of the spleen 
can usually be felt below the costal margin. Sweating is often profuse 
and there may be anaemia, but heart complications are rare. The chil- 
dren look puny and generally show arrest of development. 

Diagnosis. — Arthritis deformans in an advanced stage can rarely be 
mistaken for either rheumatism or gout. Early cases are difficult or impos- 
sible to distinguish from chronic rheumatism. It is important to distin- 
guish from the mono-articular form the local arthritis of the shoulder- joint 
which is characterized by pain, thickening of the capsule and of the liga- 
ments, wasting of the shoulder-girdle muscles, and sometimes by neuritis. 
This is an affection which is quite distinct from arthritis deformans, and is, 
moreover, in a majority of cases curable. 

Treatment. — Once established*, the disease is rarely curable. After 
attacking two or three joints it may be arrested. Too often it is a slow, 
but progressive, crippling of the joints, with a disability that makes the 
disease one of the most terrible of human afflictions. 

In the acute febrile form, usually mistaken for rheumatic fever, moder- 
ate doses of the salicylates should be given, and the joints require the 
local measures mentioned in the section on acute rheumatism. 

The treatment of the ordinary form may be considered under: 

(1) Medicinal. — No single remedy is of special value. General tonics 
are indicated. Arsenic in full doses is helpful in some cases. Potassium 
iodide is useful in the form with much periarthritis. 

(2) General Hygiene and Diet. — The disease is one of progressive debil- 
ity, and measures of a supporting character are indicated. Fresh air and 
careful attention to personal hygiene are most essential. The question 
of diet is of the first importance. There is one rule — let the patient eat 
all the good food she can digest. So many persons are afflicted not only 
with the disease, but reduced by dieting, that I often find " full diet " the 
best prescription. One has to remember that gastro-intestinal disturb- 
ances are common in the disease. 

(3) Hydrotherapy. — Early and thorough treatment at the thermal 
springs offers the best, hope of arresting the progress. The Hot Springs, 
Bath County, Va., and the Hot Springs, Ark., in this country, and those of 
Bath, England, give very good results. Much may be effected at home by 
hot-air baths, hot baths, and compresses at night to the tender joints. 

(4) Local Treatment. — Massage, carefully given, reduces the periarticu- 
lar infiltrations, increases the mobility of stiffened joints, and, most impor- 
tant of all, prevents the atrophy of the muscles adjacent to the affected 
joints. The hot-air treatment, thoroughly carried out, helps many cases, 
and should be given a trial. 

And lastly, surgical measures may be needed. The thermo-cautery is 
most useful in relieving the pain and in lessening the ligamentous thicken- 
ing. Eepeated applications are helpful along the spine in the spondylitis 
deformans. Goldthwaite and others have reported good results from the 
breaking up of adhesions and the use of orthopedic appliances. 



CHRONIC RHEUMATISM. 



405 



II. CHRONIC RHEUMATISM. 

Etiology. — This affection may follow an acute or subacute attack, but 
more commonly comes on insidiously in persons who have passed the 
middle period of life. In my experience it is extremely rare as a sequence 
of acute rheumatism. It is most common among the poor, particularly 
washer-women, day-laborers, and those whose occupation exposes them to 
cold and damp. 

Morbid Anatomy. — The synovial membranes are injected, but there 
is usually not much effusion. The capsule and ligaments of the joints are 
thickened, and the sheaths of the tendons in the neighborhood undergo 
similar alterations, so that the free play of the joint is greatly impaired. 
In long-standing cases the cartilages also undergo changes, and may show 
•erosions. Even in cases with the severest symptoms, the joint may be 
very slightly altered in appearance. Important changes take place in the 
muscles and nerves adjacent to chronically inflamed joints, particularly 
in the mono-articular lesions of the shoulder or hip. Muscular atrophy 
supervenes partly from disuse, partly through nervous influences, either 
•centric or reflex (Yulpian), or as a result of peripheral neuritis. In some 
-cases when the joint is much distended the wasting may be due to pressure, 
either on the muscles themselves or on the vessels supplying them. 

Symptoms. — Stiffness and pain are the chief features of chronic 
rheumatism. The latter is very liable to exacerbations, especially dur- 
ing changes in the weather. The joints may be tender to the touch and a 
little swollen, but are seldom reddened. As a rule, many joints are affected; 
but there are instances in which the disease is confined to one shoulder, 
knee, or hip. The stiffness and pain are more marked after rest, and as the 
■day advances the joints may, with exertion, become much more supple. 
'The general health may not be seriously impaired. The disease is not im- 
mediately dangerous. Anchylosis may occur, and ultimately the joints 
may become much distorted. In many instances, particularly those in 
which the pain is severe, the general health may be seriously involved and 
the subjects become ansemic and very apt to suffer with neuralgia and dys- 
pepsia. Valvular lesions, due to slow sclerotic changes, are not uncommon. 
They are associated with, not dependent upon, the articular disease. 

The prognosis is not favorable, as a majority of the cases resist all meth- 
ods of treatment. It is, however, a disease which persists indefinitely, and 
does not necessarily shorten life. 

Treatment. — Internal remedies are of little service. It is important 
to maintain the digestive functions and to keep the general health at a 
high standard. Potassium iodide, sarsaparilla, and guaiacum are some- 
limes beneficial. The salicylates are useless. 

Local treatment is very beneficial. " Firing " with the Paqnelin cautery 
relieves the pain, and it is perhaps the best form of counter-irritation. 
Massage, with passive motion, helps to reduce swelling, and prevents anchy- 
losis. It is particularly useful in eases which are associated with atrophy 
■of the muscles. Electricity is not of much benefit. Climatic treatment 



406 



CONSTITUTIONAL DISEASES. 



is very advantageous. Many cases are greatly helped by prolonged resi- 
dence in southern Europe or Southern California. Eich patients should 
always winter in the South, and in this way avoid the cold, damp weather. 

Hydrotherapeutic measures are specially beneficial in chronic rheuma- 
tism. Great relief is afforded by wrapping the affected joints in cold cloths, 
covered with a thin layer of blanket, and protected with oiled silk. The 
Turkish bath is useful, but the full benefit of this treatment is rarely seen 
except at bathing establishments. The hot alkaline waters are particularly 
useful, and a residence at the Hot Springs of Virginia, Arkansas, or Santa 
Eosalia, Mexico, or at Banff, in the Eocky Mountains, on the Canadian 
Pacific Eailway, will sometimes cure even obstinate cases. 



III. MUSCULAR RHEUMATISM {Myalgia). 

Definition. — A painful affection of the voluntary muscles and of the 
fasciae and periosteum to which they are attached. The affection has re- 
ceived various names, according to its seat, as torticollis, lumbago, pleuro- 
dynia, etc. 

Etiology. — The attacks follow cold and exposure, the usual conditions 
favorable to the development of rheumatism. It is by no means certain 
that the muscular tissues are the seat of the disease. Many writers claim, 
perhaps correctly, that it is a neuralgia of the sensory nerves of the mus- 
cles. Until our knowledge is more accurate, however, it may be considered 
under the rheumatic affections. 

It is most commonly met with in men, particularly those exposed to 
cold and whose occupations are laborious. It is apt to follow exposure to 
a draught of air, as from an open window in a railway carriage. A sudden 
chilling after heavy exertion may also bring on an attack of lumbago. 
Persons of a rheumatic or gouty habit are certainly more prone to this 
affection. One attack renders an individual more liable to another. It is 
usually acute, but may become subacute or even chronic. 

Symptoms. — The affection is entirely local. The constitutional dis- 
turbance is slight, and, even in severe cases, there may be no fever. Pain 
is a prominent symptom. It may be constant, or m«ay occur only when 
the muscles are drawn into certain positions. It may be a dull ache, like 
the pain of a bruise, or sharp, severe, and cramp-like. It is often sufficiently 
intense to cause the patient to cry out. Pressure on the affected part usually 
gives relief. As a rule, myalgia is a transient affection, lasting from a few 
hours to a few days. Occasionally it is prolonged for several weeks. It is 
very apt to recur. 

The following are the principal varieties: 

(1) Lumbago, one of the most common and painful forms, affects the 
muscles of the loins and their tendinous attachments. It occurs chiefly in 
workingmen. It comes on suddenly, and in very severe cases completely 
incapacitates the patient, who may be unable to turn in bed or to rise from 
the sitting posture. 

(2) Stiff neck or torticollis affects the muscles of the antero-lateral 



GOUT. 



407 



region of the neck. It is very common, and occnrs most frequently in 
the young. The patient holds the head in a peculiar manner, and rotates 
the whole body in attempting to turn it. Usually the attack is confined to 
one side. The muscles at the back of the neck may also be affected. 

(3) Pleurodynia involves the intercostal muscles on one side, and in 
some instances the pectorals and serratus magnus. This is, perhaps, the 
most painful form of the disease, as the chest cannot be at rest. It is more 
common on the left than on the right side. A deep breath, or coughing, 
causes very intense pain, and the respiratory movements are restricted on 
the affected side. There may be pain on pressure, sometimes over a very 
limited area. It may be difficult to distinguish from intercostal neuralgia, 
in which affection, however, the. pain is usually more circumscribed and 
paroxysmal, and there are tender points along the course of the nerves. 
It is sometimes mistaken for pleurisy, but careful physical examination 
readily distinguishes between the two affections. 

(4) Among other forms which may be mentioned are cephalodynia, 
affecting the muscles of the head; scapulodynia, omodynia, and dorsodynia, 
affecting the muscles about the shoulder and upper part of the back. My- 
algia may also occur in the abdominal muscles and in the muscles of the 
extremities. 

Treatment. — Eest of the affected muscles is of the first importance. 
Strapping the side will sometimes completely relieve pleurodynia. No 
belief is more widespread among the public than in the efficacy of porous 
plasters for muscular pains of all sorts, particularly those about the trunk. 
If the pain is severe and agonizing, a hypodermic of morphia gives im- 
mediate relief. For lumbago acupuncture is, in acute cases, the most effi- 
cient treatment. Needles of from three to four inches in length (ordinary 
bonnet-needles, sterilized, will do) are thrust into the lumbar muscles at 
the seat of the pain, and withdrawn after five or ten minutes. In many 
instances the relief is immediate, and I can corroborate' fully the state- 
ments of Einger, who taught me this practice, as to its extraordinary and 
prompt efficacy in many instances. The constant current is sometimes 
very beneficial. In many forms of myalgia the thermo-cautery gives great 
relief. In obstinate cases blisters may be tried. Hot fomentations are 
soothing, and at the outset a Turkish bath may cut short the attack. In 
chronic cases potassium iodide may be used, and both guaiacum and sul- 
phur have been strongly recommended. Persons subject to this affec- 
tion should be warmly clothed, and avoid, if possible, exposure to cold 
and damp. In gouty persons the diet should be restricted and the alkaline 
mineral waters taken freely. Large doses of nux vomica are sometimes 
beneficial. 

IV. GOUT {Podagra). 

Definition. — A nutritional disorder, one factor of which is an ex- 
cessive formation of uric acid, characterized clinically by attacks of acute 
arthritis, by the gradual deposition of sodium urate in and about the joints, 
and by the occurrence of irregular constitutional symptoms. 



408 



CONSTITUTIONAL DISEASES. 



Etiology. — The precise nature of the disturbance in metabolism i& 
not known. There is probably defective oxidation of the foodstuffs, com- 
bined with imperfect elimination of the waste products of the body. 

Among important etiological factors in gout are the following: 

(a) Hereditary Influences. — Statistics show that in from 50 to 60 per 
cent of all cases the disease existed in the parents or grandparents. The 
transmission is supposed to be more marked from the male side. Cases, 
with a strong hereditary taint have been known to develop before puberty. 
The disease has been seen even in infants at the breast. Males are more 
subject to the disease than females. It rarely develops before the thirtieth 
year, and in a large majority of the cases the first manifestations appear' 
before the age of fifty, (b) Alcohol is the most potent factor in the etiology 
of the disease. Fermented liquors favor its development much more than 
distilled spirits, and it prevails most extensively in countries like England 
and Germany, which consume the most beer and ale. The lighter beers, 
used in this country are much less liable to produce gout than the heavier 
English and Scotch ales, (c) Food plays a role equal in importance to that 
of alcohol. Overeating without active bodily exercise is regarded as a very 
special predisposing cause. A form of gouty dyspepsia has been described. 
A robust and active digestion is, however, often met in gouty persons.. 
Gout is by no means confined to the rich. In England the combination 
of poor food, defective hygiene, and an excessive consumption of malt 
liquors makes the " poor man's gout " a common affection, (d) Lead. 
Garrod has shown that workers in lead are specially prone to gout. In 30' 
per cent of the hospital cases the patients had been painters or workers in 
lead. The association is probably to be sought in the production by this, 
poison of arterio-sclerosis and chronic nephritis. Chronic lead-poisoning 
is here frequently associated with arterio-sclerosis and contracted kidneys, 
but lead-gout is comparatively rare. Gouty deposits are, however, to be- 
found in the big-toe joint and in the kidneys in cases of chronic plumbism. 

The nature of gout is unknown. That there is faulty metabolism, asso- 
ciated in some very special way with the chemistry of uric acid, we know, 
but nothing more. The remainder is theory, awaiting refutation or con- 
firmation. The conditions of life favorable to the development of gout are 
present in too many of us after the middle period of life — more fuel in the- 
form of meat and drink than the machine needs. G. B. Balfour put it well 
when he says: " The gouty diathesis is only a comprehensive term for all 
those changes in the character and composition of the blood induced by 
the evils of civilization — deficient exercise and excess of nutriment. . . .. 
Gout, on the other hand, is the name given to all those modifications of our 
metabolism caused by the gouty diathesis, as well as to all the symptoms- 
to which those modifications give rise." 

The views regarding uric acid and its relation to gout are very nu- 
merous. 

Garrod holds that with lessened alkalinity of the blood there is an in- 
crease in the uric acid, due chiefly to diminished elimination. He attrib- 
utes the deposition of the sodium urate to the diminished alkalinity of the 
plasma, which is unable to hold it in solution. In an acute paroxysm there 



GOUT. 



409 



is an accumulation of the urates in the blood, and the inflammation is 
caused by their sudden deposit in crystalline form about the joint. 

Haig thinks that there is no increased formation of uric acid in gout, 
but that the blood is less alkaline than normal, and less able to hold the 
uric acid or its salts in solution. 

According to Sir" William Eoberts, there are three compounds of uric 
acid (H 2 U) — the neutral urate, M 2 IT, in_which the metal replaces all the 
displaceable hydrogen; the biurate, MHU, in which half the displaceable 
hydrogen is replaced by the metal; and the quadriurate, H 2 UMHU, in which 
one-fourth of the displaceable hydrogen of two molecules is replaced by the 
metal. The neutral urates do not exist in the body: the biurate only as 
biurate of soda in gouty concretions. The quadriurate is the form in which 
uric acid circulates in the blood and is excreted in the urine. It is quite 
soluble. In the gouty state, either from deficient action of the kidneys or 
from over-production of urates, the quadriurate accumulates in the blood. 
The detained quadriurate, circulating in a medium rich in sodium carbonate,, 
takes up an additional atom of the base and is converted into the biurate. 
The biurate is less soluble and less easily excreted by the kidneys. It conse- 
quently accumulates in the blood and exists first in a gelatinous and later 
in the almost insoluble crystalline form. Then precipitation is imminent 
or actually takes place. This is apt to occur where the circulation is poor 
and the temperature low, and in regions in which the lymph contains a 
relatively high percentage of sodium chloride, as in the synovial sheaths. 
Although this theory is very plausible, yet the work of Tunnicliffe and 
Eosenheim shows that there are objections to it. 

Levison (Die Harnsaurediathese, Berlin, 1893) adopts Horbaczewski's 
views that the uric acid is related especially to the nucleins of the body, 
and is derived in great part from the destruction of the white blood-cor- 
puscles, the excretion increasing pari passu with the intensity of the leuco- 
cytosis. While this is true in many diseases, as in pneumonia, Eichter, in a 
careful study, has shown that there are important exceptions. 

Ebstein thinks that the first change is a nutritive tissue disturbance, 
which leads to necrosis, and in the necrotic areas the urates are deposited 
— a view which has been modified by von Noorden, who holds that a spe- 
cial ferment leads to the tissue change, to which the deposit of the urates 
is secondary. 

Kolisch believes that gout is due to the action of the xanthin bases. 
He holds that they are increased in gout, because, he thinks, the kidneys, 
are diseased and unable to convert the nucleic acid derivatives into uric 
acid in sufficient amounts. Garrod and Luff also both hold that uric acid 
is normally produced only in the kidneys. Latham also is of the opinion 
that the final formation of uric acid takes place in the kidneys, where it 
is produced by the union of substances formed in the liver and conveyed 
to them by the blood current. The question of the final seat of the 
formation of uric acid is still unsolved; experimental research has as yet 
failed to give uniform results. 

( alien held that gout was primarily an affection of the nervous system. 
On this nervous theory of gout there is a basic, arthritic stock — a diathetic 



410 



CONSTITUTIONAL DISEASES. 



habit, of which gout and rheumatism are two distinct branches. The 
gouty diathesis is expressed in (a) a neurosis of the nerve-centres, which 
may be inherited or acquired; and (b) " a peculiar incapacity for normal 
elaboration within the whole body, not merely in the liver or in one or two 
organs, of food, whereby uric acid is formed at times in excess, or is in- 
capable of being duly transformed into more soluble and less noxious 
products " (Duckworth). The explosive neuroses and the influence of de- 
pressing circumstances, physical or mental, point strongly to the part 
played by the nervous system in the disease. The recents works of Duck- 
worth and William Ewart may be consulted for a full discussion of the vari- 
ous theories on the nature of gout. 

Morbid Anatomy. — The blood is stated to have an excess of uric 
acid. It may be obtained from the blood-serum by the method known as 
Garrod's uric-acid thread experiment, or from the serum obtained from a 
blister. To o ij of serum add ni v-vj of acetic acid in a watch-glass. A 
thread immersed in this may show in a few hours an incrustation of uric acid. 
The experiment is rarely successful even in cases of manifest gout. This 
excess, also, is not peculiar to gout, but occurs in leukaemia and chlorosis. 

In 1894 Neusser described a peculiar black granulation over and about 
the nuclei of the leucocytes in the blood of gouty patients. He termed them 
" perinuclear basophilic granules," and demonstrated them by using a modi- 
fied Ehrlich's triacid mixture. They were particularly numerous about the 
nuclei of the mononuclear leucocytes. He believed that they were of the 
nature of a nucleo-albumin, and claimed that cases showing them eliminated 
uric acid in excess. He held that these granules constituted the mother 
substance from which the uric acid was formed, and that their presence 
was strongly indicative of a uratic or gouty diathesis. Subsequent work 
by Futcher and others seems to have shown that there is no association 
between the abundance of these granules and the elimination of uric acid 
or of the total alloxuric bodies. 

The important changes are in the articular tissues. The first joint of 
the great toe is most frequently involved; then the ankles, knees, and the 
small joints of the hands and wrists. The deposits may be in all the joints 
of the lower limbs and absent from those of the upper limbs (Norman 
Moore). If death takes place during an acute paroxysm, there are signs 
of inflammation, hyperemia, swelling of the ligamentous tissues, and of 
effusion into the joint. The primary change, according to Ebstein, is a 
local necrosis, due to the presence of an excess of urates in the blood. This 
is seen in the cartilage and other articular tissues in which the nutritional 
currents are slow. His and Mordhorst hold that the deposition of the 
urates is primary, and that the tissue necrosis takes place as a result of this 
deposit. In these areas of coagulation necrosis the reaction is always acid 
and the neutral urates are deposited in crystalline form, as insoluble acid 
urates. The articular cartilages are first involved. The gouty deposit may 
be uniform, or in small areas. Though it looks superficial, the deposit is 
invariably interstitial and covered by a thin lamina of cartilage. The de- 
posit is thickest at the part most distant from the circulation. The liga- 
ments and fibro-cartilage ultimately become involved and are infiltrated 



GOUT. 



411 



with chalky deposits, the so-called chalk-stones, or tophi. These are usually 
-covered by skin; but in some cases, particularly in the metacarpo-phalangeal 
articulations, this ulcerates and the chalk-stones appear externally. The 
synovial fluid may also contain crystals. In very long-standing cases, owing 
to an excessive deposit, the joint becomes immobile. The marginal out- 
growths in gouty arthritis are true exostoses (Wynne). The cartilage of 
the ear may contain tophi, which are seen as whitish nodules at the margin 
of the helix. The cartilages of the nose, eyelids, and larynx are less fre- 
quently affected. 

Of changes in the internal organs, those in the renal and vascular sys- 
tems are the most important. The kidney changes believed to be charac- 
teristic of gout are: (a) A deposit of urates chiefly in the region of the 
papilla?. This, however, is less common than is usually supposed. Norman 
Moore found it in only 12 out of 80 cases. The apices of the pyramids show 
lines of whitish deposit. On microscopical examination the material is seen 
to be largely in the intertubular tissue. In some instances, however, the 
deposit seems to be both in the tissue and in the tubules. Ebstein has de- 
scribed and figured areas of necrosis in both cortex and medulla, in the 
interior of which were crystalline deposits of urate of soda. The presence 
of these uratic concretions at the apices of the pyramids is not a positive 
indication of gout. They are not infrequent in this country, in which gout 
is rare, (b) An interstitial nephritis, either the ordinary " contracted kid- 
ney " or the arterio-sclerotic form, neither of which are in any way dis- 
tinctive. It is not possible to say in a given case that the condition has 
been due to gout unless marked evidences of the disease coexist. 

The metatarso-phalangeal joint of the big toe should be carefully ex- 
amined, as it may show typical lesions of gout without any outward token 
of arthritis. 

Arterio-sclerosis is a very constant lesion. With it the heart, particu- 
larly the left ventricle, is found hypertrophied. According to some authors, 
concretions of urate of soda may occur on the valves. 

Changes in the respiratory system are rare. Deposits have been found 
in the vocal cords, and uric-acid crystals have been met in the sputa of a 
gouty patient (J. W. Moore). Emphysema is a very constant condition 
in old cases. 

Symptoms. — Gout is usually divided into acute, chronic, and irregu- 
lar forms. 

Acute Gout. — Premonitory symptoms are common — twinges of pain in 
the small joints of the hands or feet, nocturnal restlessness, irritability of 
temper, and dyspepsia. The urine is acid, scanty, and high-colored. It 
deposits urates on cooling, and there may be, according to Garrod, tran- 
sient albuminuria. There may be traces of sugar (gouty glycosuria). Before 
an attack the output of uric acid is low and is also diminished in the early 
part of the paroxysm. The relation of uric and phosphoric acids to the 
acute attacks is well represented in Chart XIY, prepared by Futcher. Both 
were extremely low in the intervals, bul reached within normal limits short- 
ly after the onset of the acute symptoms. The phosphoric acid and uric 



412 



CONSTITUTIONAL DISEASES. 



acid show almost parallel curves. The patient was on a very light fixed diet, 
at the time the determinations were made. Bain holds that the phosphoric 
acid excretion varies directly with that of the nric acid. Watson claims, 
that there is no relationship between the two. In some instances the throat- 




is sore, and there may be asthmatic symptoms. The attack sets in usually 
in the early morning hours. The patient is aroused by a severe pain in the 
metatarsophalangeal articulation of the big toe, and more commonly ou 



GOUT. 



413 



the right than on the left side. The pain is agonizing, and, as Sydenham 
says, " insinuates itself with the most exquisite cruelty among the numer- 
ous small bones of the tarsus and metatarsus, in the ligaments of which it 
is lurking." The joint swells rapidly, and becomes hot, tense, and shiny. 
The sensitiveness is extreme, and the pain makes the patient feel as if the 
joint were being pressed in a vice. There is fever, and the temperature may 
rise to 102° or 103°. Toward morning the severity of the symptoms sub- 
sides, and, although the joint remains swollen, the day may be passed in 
comparative comfort. The symptoms recur the next night, and the fit, 
as it is called, usually lasts for from five to eight days, the severity of the 
symptoms gradually abating. Occasionally other joints are involved, par- 
ticularly the big toe of the opposite foot. The inflammation, however in- 
tense, never goes on to suppuration. With the subsidence of the swelling 
the skin desquamates. After the attack the general health may be much 
improved. As Aretseus remarks, a person in the interval has won the race 
at the Olympian games. Eecurrences are frequent. Some patients have 
three or four attacks in a year; others suffer at longer intervals. 

The term reirocedent or suppressed gout is applied to serious internal 
symptoms, coincident with a rapid disappearance or improvement of the 
local signs. Very remarkable manifestations may occur under these cir- 
cumstances. The patient may have severe gastro-intestinal symptoms — 
pain, vomiting, diarrhoea, and great depression — and death may occur dur- 
ing such an attack. Or there may be cardiac manifestations — dyspnoea, 
pain, and irregular action of the heart. In some instances in which the 
gout is said to attack the heart, an acute pericarditis develops and proves 
fatal. So, too, there may be marked cerebral manifestations — delirium 
or coma, and even apoplexy — but in a majority of these instances the 
symptoms are, in all probability, uraemic. 

Gout is a comparatively rare disease in America. Among the well-to-do, 
and even among club-men — a class particularly liable — it is infrequent, in 
comparison with the prevalence in the corresponding classes in England. 
Men in large family practices may pass a year or more without seeing a 
case. To May 15, 1901, there were during 12 years only 32 cases of mani- 
fest gout admitted to my wards, all white males. 

Chronic Gout. — With increased frequency in the attacks, the articular 
symptoms persist for a longer time, and gradually many joints become 
affected. Deposits of urates take place, at first in the articular cartilages 
wild then in the ligaments and capsular tissues; so that in the course of 
years the joints become swollen, irregular, and deformed. The feet are 
usually first affected, then the hands. In severe cases there may be exten- 
sive concretions about the elbows and knees and along the tendons and in 
the bursa*. The tophi appear in the ears. Finally, a unique clinical picture 
is produced which can not be mistaken for that of any other affection. The 
skin over the tophi may rupture or ulcerate, and about the knuckles the 
chalk-stones may he freely exposed. Patients with chronic goui are usually 
dyspeptic, often of a sallow complexion, and show signs of arterio-sclerosis. 
The pulse tension is increased, the vessels arc stiff, and the left ventricle 
is hypertrophic^!. The urine is increased in amount, is of low specific grav- 
2G 



414 



CONSTITUTIONAL DISEASES. 



ity, and usually contains a slight amount of albumin, with a few hyaline 
casts. Intercurrent attacks of acute polyarthritis may develop, in which 
the joints become inflamed, and the temperature ranges from 101° to 103°. 
There may be pain, redness, and swelling of several joints without fever. 
Uraemia, pleurisy, pericarditis, peritonitis, and meningitis are common 
terminal affections. The victim of gout may show remarkable mental 
and even bodily vigor. Certain of the most distinguished members of our 
professsion have been terrible sufferers from this disease, notably the elder 
Scaliger, Jerome Cardan, and Sydenham, whose statement that " more 
wise men than fools are victims of the affection " still holds good. 

Irregular Gout. — This is a motley, ill-defined group of symptoms, mani- 
festations of a condition of disordered nutrition, to which the terms gouty 
diathesis or lithcemic state have been given. Cases are seen in members of 
gouty families, who may never themselves have suffered from the acute 
disease, and in persons who have lived not wisely but too well, who have 
eaten and drunk largely, lived sedentary lives, and yet have been fortunate 
enough to escape an acute attack. It is interesting to note the various 
manifestations of the disease in a family with marked hereditary disposi- 
tion. The daughters often escape, while one son may have gouty attacks 
of great severity, even though he lives a temperate life and tries in every 
way to avoid the conditions favoring the disorder. Another son has, per- 
haps, only the irregular manifestations and never the acute articular affec- 
tion. While the irregular features are perhaps more often met with in 
the hereditary affection, they are by no means infrequent in persons who 
appear to have acquired the disease. The tendency in some families is to 
call every affection gouty. Even infantile complaints, such as scald-head, 
naso-pharyngeal vegetations, and enuresis, are often regarded, without suf- 
ficient grounds, I believe, as evidences of the family ailment. Among the 
commonest manifestations of irregular gout are the following: 

(a) Cutaneous Eruptions. — Garrod and others have called special atten- 
tion to the frequent association of eczema with the gouty habit. The 
French in particular insist upon the special liability of gouty persons to 
skin affections, the arthritides, as they call them. 

(b) G astro-intestinal Disorders. — Attacks of what is termed biliousness, 
in which the tongue is furred, the breath foul, the bowels constipated, and 
the action of the liver torpid, are not uncommon in gouty persons. A 
gouty parotitis is described. 

(c) C ardio-vascular Symptoms. — With the lithsemia, arterio-sclerosis is 
frequently associated. The blood tension is persistently high, the vessel 
walls become stiff, and cardiac and renal changes gradually develop. In 
this condition the manifestations may be renal, as when the albuminuria 
becomes more marked, or dropsical symptoms supervene. The manifesta- 
tions may be cardiac, when the hypertrophy of the left ventricle fails and 
there are palpitation, irregular action, and ultimately a condition of asys- 
tole. Or, finally, the manifestations may be vascular, and thrombosis of 
the coronary arteries may cause sudden death. Aneurism may develop and 
prove fatal, or, as most frequently happens, a blood-vessel gives way in 
the brain, and the patient dies of apoplexy. It makes but little difference 



GOUT. 



415 



whether we regard this condition as primarily an arterio-sclerosis, or as a 
gouty nephritis; the point to be remembered is that the nutritional dis- 
order with which an excess of uric acid is associated induces in time in- 
creased tension, arterio-sclerosis, chronic interstitial nephritis, and changes 
in the myocardium. Pericarditis is not an infrequent terminal complica- 
tion of gout. 

(d) Nervous Manifestations. — Headache and megrim attacks are not 
infrequent. Haig attributes them to an excess of uric acid. Neuralgias are 
not uncommon; sciatica and paresthesias may develop. A common gouty 
manifestation, upon which Duckworth has laid stress, is the occurrence of 
hot or itching feet at night. Plutarch mentions that Strabo called this 
symptom " the lisping of the gout." Cramps in the legs may also be very 
troublesome. Hutchinson has called attention to hot and itching eyeballs 
as a frequent sign of masked gout. Associated or alternating with this 
symptom there may be attacks of episcleral congestion. Apoplexy is a 
common termination of gout. t Meningitis may develop, usually basilar. 

(e) Urinary Disorders. — The urine is highly acid and high-colored, and 
may deposit on standing crystals of lithic acid. Transient and temporary 
increase in this ingredient can not be regarded as serious. In many cases 
of chronic gout the amount may be diminished, and only increased at cer- 
tain periods, forming the so-called uric-acid showers. The chart on page 
412 illustrates this very well. Sugar is found intermittently in the urine 
of gouty persons — gouty glycosuria. It may pass into true diabetes, but is 
usually very amenable to treatment. Oxaluria may also be present. Gouty 
persons are specially prone to calculi, Jerome Cardan to the contrary, who 
reckoned freedom from stone among the chief of the dona podagra. Minute 
quantities of albumin are very common in persons of gouty dyscrasia, and, 
when the renal changes are well established, tube-casts. Urethritis, accom- 
panied with a well-marked purulent discharge, may develop, so it is stated, 
usually at the end of an attack. It may occur spontaneously, or follow a 
pure connection. 

(f) Pulmonary Disorders. — There are no characteristic changes, but, 
as Greenhow has pointed out, chronic bronchitis occurs with great fre- 
quency in persons of a gouty habit. 

(g) Of eye affections, iritis, glaucoma, hemorrhagic retinitis, and sup- 
purative panopthalmitis have been described. 

Diagnosis. — Recurring attacks of arthritis, limited to the big toe and 
to the tarsus, occurring in a member of a gouty family, or in a man who 
has lived too well, leave no question as to the nature of the trouble. There 
are many cases of gout, however, in which the feet do not suffer most se- 
verely. After an attack or two in one toe, other joints may be affected, 
and it is just in such cases of polyarthritis that the difficulty in diagnosis is 
apt to arise. We have had of late years several cases admitted for the third 
or fourth 1 ime with involvement of three or more of the larger joints. The 
presence of tophi has settled the nature of a trouble which in the previous 
attacks had been regarded as rheumatic. The following are suggestive 
points in such cases: (1) The patient's habits and occupation. In this coun- 
try the brewery men and barkeepers are often affected. (2) The presence 



416 



CONSTITUTIONAL DISEASES. 



of tophi. The ears should always be felt in a case of polyarthritis. The 
diagnosis may rest with a small tophus. The student should learn to recog- 
nize on the ear margin, Woolner's tip, fibroid nodules, and small sebaceous 
tumors. The last are easily recognized microscopically. The sodium 
urate crystals are distinctive in the tophi. (3) The condition of the urine. 
As shown in Chart XIV, the uric-acid output is usually very low during 
the intervals of the paroxysm. There may, indeed, be no excretion what- 
ever. At the height of the attack the elimination, as a rule, is greatly in- 
creased. The ratio of the uric acid to the urea excretion is disturbed in 
gouty cases, and may fall as low as 1 to 100 to 1 to 150. (4) The gouty poly- 
arthritis may be afebrile. A patient with three or four joints red, swollen, 
and painful in acute rheumatism has fever, and, while pyrexia may be pres- 
ent and often is in gout, its absence is, I think, a valuable diagnostic sign. 

Treatment. — Hygienic. — Individuals who have inherited a tendency 
to gout, or who have shown any manifestations of it, should live temper- 
ately, abstain from alcohol, and eat moderately. An open-air life, with 
plenty of exercise and regular hours, does much to counteract an inborn 
tendency to the disease. The skin should be kept active: if the patient is 
robust, by the morning cold bath with friction after it; but if he is weak 
or debilitated the evening warm bath should be substituted. An occa- 
sional Turkish bath with active shampooing is very advantageous. The 
patient should dress warmly, avoid rapid alterations in temperature, and 
be careful not to have the skin suddenly chilled. 

Dietetic. — "With few exceptions, persons over forty eat too much, and 
the first injunction to a gouty person is to keep his appetite within reason- 
able bounds, to eat at stated hours, and to take plenty of time at his meals. 
In the matter of food, quantity is a factor of more importance than quality 
with many gouty persons. As Sir William Eoberts well says, " Nowhere 
perhaps is it more necessary than in gout to consider the man as well as 
the ailment, and very often more the man than the ailment." 

Very remarkable differences of opinion exist as to the most suitable 
diet in this disease, some urging warmly a vegetable diet, others allowing 
a very liberal amount of meat. On the one hand, the author just quoted 
says: " The most trustworthy experiments indicate that fat, starch, and 
sugar have not the least direct influence on the production of uric acid; 
but as the free consumption of these articles naturally operates to restrict 
the intake of the nitrogenous food, their use has indirectly the effect of 
diminishing the average production of uric acid." On the other hand, 
W. H. Draper says: " The conversion of azotized food is more complete 
with a minimum of carbohydrates than it is with an excess of them; in 
other words, one of the best means of avoiding the accumulation of lithic 
acid in the blood is to diminish the carbohydrates rather than the azotized 
foods." The weight of opinion leans to the use of a modified nitrogenous 
diet, without excess in starchy and saccharine articles of food. Fresh vege- 
tables and fruits may be used freely, but among the latter strawberries and 
bananas should be avoided. 

Ebstein urges strongly the use of fat in the form of good fresh butter, 
from 2 J to 3 J ounces in the day. He says that stout gouty subjects not 



GOUT. 



417 



only do not increase in weight with plenty of fat in the food, but that they 
actually become thin and the general condition improves very much. Hot 
bread of all sorts and the various articles of food prepared from Indian 
corn should, as a rule, be avoided. Eoberts advises gouty patients to re- 
strict as far as practicable the use of common salt with their meals, since 
the sodium biurate very readily crystallizes out in tissues with a high per- 
centage of sodium salts. 

In this matter of diet each individual case must receive separate con- 
sideration. 

There are very few conditions in the gouty in which stimulants of any 
sort are required. Whenever indicated, whisky will be found perhaps the 
most serviceable. While all are injurious to these patients, some are much 
more so than others, particularly malted liquors, champagne, port, and a 
very large proportion of all the light wines. 

Mineral Waters. — All forms may be said to be beneficial in gout, as the 
main element is the water, and the ingredients are usually indifferent. 
Much of the humbuggery in the profession still lingers about mineral waters, 
more particularly about the so-called lithia waters. For a careful consid- 
eration of the question the reader is referred to William Ewart's recent 
work on Gout and Goutiness. 

The question of the utility of alkalies in the treatment of gout is 
closely connected with this subject of mineral waters. This deep-rooted 
belief in the profession was rudely shaken a few years ago by Sir William 
Eoberts, who claims to have shown conclusively that alkalescence as such 
has no influence whatever on the sodium biurate. The sodium salts are 
believed by this author to be particularly harmful, but, in spite of all the 
theoretical denunciation of the use of the sodium salts in gout, the gouty 
from all parts of the world flock to those very Continental springs in which 
these salts are most predominant. Bain urges the use of potassium salts. 

Of the mineral springs best suited for the gouty may be mentioned, 
in this country, those of Saratoga, Bedford, and the White Sulphur; Buxton 
and Bath, in England; in France, Aix-les-Bains and Contrexeville; and in 
Germany, Carlsbad, Wildbad, and Homburg. 

The efficacy in reality is in the water, in the way it is taken, on an 
empty stomach, and in large quantities; and, as every one knows, the im- 
portant accessories in the modified diet, proper hours, regular exercise, 
with baths, douches, etc., play a very important role in the " cure." 

Medicinal Treatment. — In an acute attack the limb should be elevated 
and the affected joint wrapped in cotton-wool. Warm fomentations, or 
Fuller's lotion, may be used. The local hot-air treatment may be tried. 
A brisk mercurial purge is always advantageous at the outset. The wine 
or tincture of colchicum, in doses of 20 to 30 minims, may be given every 
four hours in combination with the citrate of potash or the citrate of 
lithium. The action of the colchicum should be carefully watched. It 
has, in a majority of the cases, a powerful influence over the symptoms — 
relieving the pain, and reducing, sometimes with great rapidity, the swell- 
ing and redness. It should be promptly stopped so soon as it has relieved 
the pain. In cases in which the pain and sleeplessness are distressing and 



418 



CONSTITUTIONAL DISEASES. 



do not yield to colchicine morphia is necessary. The patient should be 
placed on a diet chiefly of milk and barley-water, but if there is any de- 
bility, strong broths may be given, or eggs. It is occasionally necessary to 
give small quantities of stimulants. During convalescence meats and fish 
and game may be taken, and gradually the patient may resume the diet 
previously laid down. 

In some of the subacute intercurrent attacks of arthritis in old, de- 
formed joints, the sodium salicylate is occasionally useful, but its adminis- 
tration must be watched in cases of cardiac and renal insufficiency. It is 
also much advocated by Haig in the uric-acid habit. 

The chronic and irregular forms of gout are best treated by the dietetic 
and hygienic measures already referred to. Potassium iodide is some- 
times useful, and preparations of guaiacum, quinine, and the bitter tonics 
combined with alkalies are undoubtedly of benefit. 

Piperazin has been much lauded as an efficient aid in the solution of 
uric acid. The clinical results, however, are very discordant. It may be 
employed in doses of from 15 to 30 grains in the day, and is conveniently 
given in aerated water containing 5 grains to the tumblerful. 



V. DIABETES MELLITUS. 

Definition. — A disorder of nutrition, in which sugar accumulates in 
the blood and is excreted in the urine, the daily amount of which is greatly 
increased. 

For a case to be considered one of diabetes mellitus it is necessary, ac- 
cording to von Noorden, that the form of sugar eliminated in the urine 
be grape sugar, that it must be eliminated for weeks, months, or years, and 
that the excretion of sugar must take place after the ingestion of moderate 
amounts of carbohydrates. 

Etiology. — Hereditary influences play an important role, and cases 
are on record of its occurrence in many members of the same family. 
Morton (Phthisiologia, 1689, pp. 43 and 44) gives two remarkable family 
cases. In one four children were affected, one of whom recovered on a 
milk diet and diascordium. An analysis of 112 cases in my series gave only 
6 cases with a history of diabetes in relatives (Pleasants). Naunyn ob- 
tained a family history of diabetes in 35 out of 201 private cases, but in 
only 7 of 157 hospital cases. There are instances of the coexistence of 
the disease in man and wife. Schmidt first drew attention to the possibility 
of diabetes being contagious. Out of his series of 2,320 cases he believed 
that 26 instances were the result of contagion. In the majority of the cases 
the wife contracted the disease later than the husband. Sex. — Men are 
more frequently affected than women, the ratio being about three to two. 
Up to May 15, 1901, 156 cases of diabetes had been treated in the medical 
wards and medical dispensary of the Johns Hopkins Hospital, 95 of which 
were in males and 61 in females. It is a disease of adult life; a majority 
of the cases occur from the third to the sixth decade. Of the 156 cases, 
the largest number — 46, or 23 per cent — occurred between fifty and sixty 



DIABETES MELLITQS. 



419 



years of age. These figures agree fairly closely with those of Frerichs, 
Seegen, and Pavy, all of whom found the largest number of cases in the 
sixth decade, their percentages being 26, 30, and 30.7 respectively. It is 
rare in childhood, but cases are on record in children under one year of 
age. Persons of a neurotic temperament are often affected. It is a disease 
of the higher classes. Von Noorden states that the statistics for London 
and Berlin show that the number of cases in the upper ten thousand ex- 
ceeds that in the lower hundred thousand inhabitants. Race. — Hebrews 
seem especially prone to it; one fourth of Frerichs' patients were of the 
Semitic race. I have been much impressed with the frequency of the dis- 
ease among them. Of the last 16 cases which I have had in private practice, 
8 were in Hebrews. Diabetes is comparatively rare in the colored race, but 
not so uncommon as was formerly supposed. Of the series of 156 cases, 15, 
or 9.6 per cent were in negroes. The ratio of males to females affected 
is almost exactly the reverse of that in the white race; 6 of the 15 cases were 
in males and 9 in females. In a considerable proportion of the cases of 
diabetes the subjects have been excessively fat at the beginning of, or prior 
to, the onset of the disease. A slight trace of sugar is not very uncommon 
in obese persons. This so-called lipogenic glycosuria is not of grave signifi- 
cance, and is only occasionally followed by true diabetes. On the other 
hand, as von Noorden has shown, there may be a " diabetogenous obesity/' 
in which diabetes and obesity develop in early life, and these cases are very 
unfavorable. There are instances on record in which obesity with diabetes 
has occurred in three generations. Diabetes is more common in cities than 
in country districts. Gout, syphilis, and malaria have been regarded as pre- 
disposing causes. Burdel and Calmette think that malaria is an important 
predisposing etiological factor. In only 1 of the 156 cases could malaria 
be considered more than a possible cause of the diabetes (Futcher). Mental 
shock, severe nervous strain, and worry precede many cases. In one case 
the symptoms came on suddenly after the patient had been nearly suffocated 
by smoke from having been confined in a cell of a burning jail. Shock 
and the toxic effects of the smoke may both have been factors in this case. 
The combination of intense application to business, over-indulgence in food 
and drink, with a sedentary life, seems particularly prone to induce the dis- 
ease. Glycosuria may set in during pregnancy, and in rare instances may 
only occur at this period. Trousseau thought that the offspring of phthisi- 
cal parents were particularly prone to diabetes. Injury to or disease of the 
spinal cord or brain has been followed by diabetes. In the carefully ana- 
lyzed cases of Frerichs there were 30 instances of organic disease of these 
parts. The medulla is not always involved. In only 4 of his cases, which 
showed organic disease, was there sclerosis or other anomaly of this part. 
An irritative lesion of Bernard's diabetic centre in the medulla is an occa- 
sional cause. I saw with Reiss, at the Friedrichshain, Berlin, a woman who 
had anomalous cerebral symptoms and diabetes, and in whom there was 
found post mortem a eysticercus in the fourth ventricle. Ebstein lias re- 
cently recorded 4 cases in which there was a coincident occurrence of epi- 
lepsy and diabetes mellitus. He thinks that in the majority of cases the 
two diseases arc dependent on a common cause. He believes that the asso- 



420 



CONSTITUTIONAL DISEASES. 



ciation would be found much, more commonly in Jacksonian epilepsy than 
has been the case heretofore, if more careful and systematic examinations 
of the urine were made. 

The disease has occasionally followed the infectious fevers. Cases have 
been recorded as occurring during or immediately after diphtheria, influ- 
enza, rheumatism, enteric fever, and syphilis. Again, a few have followed 
injury without implication of the brain or cord. Leo believes that diabetes 
is due to a toxic agent. He has produced glycosuria in dogs by adminis- 
tering both fresh and fermented diabetic urine. 

In comparison with its incidence in European countries diabetes is a rare 
disease in America. The last census gave only 3.8 per 100,000 of popula- 
tion, against a ratio of from 5 to 14 in the former. The death-rate has been 
gradually on the increase in Paris during the last three or four decades, 
reaching 14 to the 100,000 of population in 1891. For the same year the 
mortality in Malta was 13.1 to the 100,000 of population. The disease is 
gradually on the increase in the United States. The statistics for 1870 gave 
2.1; for 1880, 2.8; and for 1890, 3.8 deaths to the 100,000 population. In 
this region the incidence of the disease may be gathered from the fact that 
among 239,000 patients under treatment at the Johns Hopkins Hospital 
and Dispensary during the twelve years since its opening there have been 
161 cases. During the twelve years 76,000 medical cases were treated, the 
156 diabetic cases constituting only 0.20 per cent of these. 

We are ignorant of the nature of the disease. Normally the carbo- 
hydrates taken with the food are stored in the liver and in the muscles as 
glycogen, and then utilized as needed by the system. Glycogen can also 
be formed from the proteids of the food, and under certain circumstances 
sugar may be directly formed from the body proteids. Whenever the 
sugar in the systemic blood exceeds a definite amount (about 0.2 per cent) 
it is discharged by the kidneys, producing glycosuria. Theoretically dia- 
betes may be supposed to be induced by: 

(a) The ingestion of a larger quantity of carbohydrates and peptones 
than can be warehoused, so to speak, in the liver as glycogen, so that part 
has to pass over into the hepatic blood. Some of the instances of lipogenic 
or dietetic glycosuria are of this nature. 

(b) Disturbances of the liver function: (1) Changes in the circulation 
under nervous influences. Puncture of the medulla, lesions of the cord, 
and central irritation of various kinds are followed by glycosuria, which 
is attributed to a va so-motor paralysis (more rapid blood-flow) induced 
by these causes. On this view the disease is a neurosis. (2) Instability of 
the glycogen, owing either to imperfect formation or to conditions in the 
cells which render it less stable. Phloridzin and other substances which 
cause diabetes very probably act in this way; phloridzin acts primarily on 
the renal epithelium, destroying its power of keeping back the sugar. As 
to the possibility of a renal form of diabetes in man, consult Naunyn, 
page 106. 

(c) Defective assimilation of the glucose in the system. How and under 
what normal circumstances the sugar is utilized we do not yet know. 
Theoretically faulty metabolism would explain the condition. 



DIABETES MELLITUS. 



421 



Morbid Anatomy. — Saunclby (Lectures on Diabetes, 1891) lias given 
a good summary of the anatomical changes: 

The nervous system shows no constant lesions. In a few instances there 
have been tumors or sclerosis in the medulla, or, as in the case above men- 
tioned, a cysticercus has pressed on the floor. Cysts have been met with 
in the white matter of the cerebrum and perivascular changes have been 
described. Glycogen has been found in the spinal cord. In the peripheral 
nervous system there are instances in which tumors have been found press- 
ing on the vagus. A secondary multiple neuritis is not rare, and to it the 
so-called diabetic tabes is probably due. K. T. Williamson has found 
changes in the posterior columns of the cord similar to those which occur 
in pernicious anaemia. 

In the sympathetic system the ganglia have been enlarged and in some 
instances sclerosed, but there is nothing peculiar in these changes. The 
blood may contain as high as 0.4 per cent of sugar instead of 0.15 per cent. 
The plasma is usually loaded with fat, the molecules of which may be seen 
as fine particles. When drawn, a white creamy layer coats the coagulum, 
and there may be lipaemic clots in the small vessels. There are no special 
changes in the red or white corpuscles. The polynuclear leucocytes con- 
tain glycogen. Glycogen can occur in normal blood, but it is here extra- 
cellular. It has been also found in the polynuclear leucocytes in leukaemia. 
The heart is hypertrophied in some cases. Endocarditis is very rare. 
Arterio-sclerosis is common. The lungs show important changes. Acute 
broncho-pneumonia or croupous pneumonia (either of which may terminate 
in gangrene) and tuberculosis are common. The so-called diabetic phthisis 
is always tuberculous and results from a caseating broncho-pneumonia. In 
rare cases there is a chronic interstitial pneumonia, non-tuberculous. Fat 
embolism of the pulmonary vessels has been described in connection with 
diabetic coma. 

The liver is usually enlarged; fatty degeneration is common. In the 
so-called diabetic cirrhosis — the cirrhose pigment aire — the liver is enlarged 
and sclerotic, and a cachexia develops with melanoderma. This condition 
is probably identical with haemachromatosis. Dilatation of the stomach 
is common. 

The Pancreas in Diabetes. — The present status may be thus sum- 
marized: (a) Extirpation of the gland in dogs (and occasionally in man 
— W. T. Bull) is followed by glycosuria. If a small portion remains, sugar 
does not appear, (b) In a considerable percentage of cases of diabetes 
lesions of the pancreas are found; 50 per cent (Hansemann, Williamson) 
show a chronic interstitial inflammation, (c) In view of the experimental 
work, it is reasonable to infer that the diabetes is secondary to the pan- 
creatic lesion. The organ has, like the liver, a double secretion — an ex- 
ternal, which is poured into the intestines, and an internal, of the nature 
of a ferment, in the presence of which alone the normal assimilative pro- 
cesses can take place with the glycogen. Disease of the pancreas causes 
diabetes by preventing the formation of the glycolytic ferment. The fact 
that it' a small portion of the gland is left, in the experiments upon dogs, 
diabetes docs not occur, is analogous to the remarkable circumstance that 



422 



CONSTITUTIONAL DISEASES. 



a small fragment of the thyroid is sufficient to prevent the development 
of artificial myxcedema. 

It is probable that the observations of Opie from Dr. Welch's laboratory 
give a key to the problem. Imbedded in the gland are the peculiar bodies 
known as the islands of Langerhaus, composed of polygonal cells arranged 
in irregular columns, between which are wide anastomosing capillaries. 
The lumina of the ducts do not enter the islands, which are in reality duct- 
less glands, like the para-thyroid, the thyroid, the pituitary, etc. The in- 
timate relation of the Columns of cells to the rich network of blood-vessels 
suggest that they furnish the internal secretion of the gland as advanced 
by Schafer. Experimental evidence is defective, but changes in the islands 
have been found in diabetes. In a diabetic woman, aged twenty-four, from 
my wards, dead of tuberculosis of the lungs, Opie found the glandular tissue 
of the pancreas well preserved and healthy, but the islands of Langerhaus 
were everywhere " represented by a sharply circumscribed hyaline struc- 
ture composed of particles of homogeneous material." In two other cases 
lesions of the islands were found, but there was also chronic pancreatitis 
(Opie, Jour. Exper. Med., vol. v). 

Of 15 autopsies from my own 27 cases, in 9 on gross examination the 
pancreas was found to be atrophic. In one of these fat necroses, and in 
another calculi, were present. 

The kidneys show usually a diffuse nephritis with fatty degeneration. 
A hyaline change occurs in the tubal epithelium, particularly of the de- 
scending limb of the loop of Henle, and also in the capillary vessels of the 
tufts. 

Symptoms. — Acute and chronic forms are recognized, but there is 
no essential difference between them, except that in the former the patients 
are younger, the course is more rapid, and the emaciation more marked. 
Acute cases may occur in the aged. I saw with Sowers in Washington a 
man aged seventy-three in whom the entire course of the disease was less 
than three weeks. 

It is also possible to divide the cases into (1) lipogenic or dietetic, which 
includes the transient glycosuria of stout persons; (2) neurotic, due to in- 
juries or functional disorders of the nervous system; and (3) pancreatic, 
in which there is a lesion of the pancreas. It is, however, by no means 
easy to discriminate in all cases between these forms. Attempts have 
been made to separate a clinical variety analogous to experimental pan- 
creatic diabetes. Hirschfeld, from Guttmann's clinic, has described cases 
running a rapid and severe course usually in young and middle-aged 
persons. The polyuria is less common or even absent, and there is a strik- 
ing defect in the assimilation of the albuminoids and fats, as shown by 
the examination of the faeces and urine. In 4 of 7 cases autopsies were 
made and the pancreas was found atrophic in two, cancerous in one, and 
in the fourth exceedingly soft. 

The onset of the disease is gradual and either frequent micturition or 
inordinate thirst first attracts attention. Very rarely it sets in rapidly, 
after a sudden emotion, an injury, or after a severe chill. When fully 
established the disease is characterized by great thirst, the passage of large 



DIABETES MELLITUS. 



423 



quantities of saccharine urine, a voracious appetite, and, as a rule, pro- 
gressive emaciation. 

Among the general symptoms of the disease thirst is one of the most 
distressing. Large quantities of water are required to keep the sugar 
in solution and for its excretion in the urine. The amount of fluid con- 
sumed will be found to bear a definite ratio to the quantity excreted. In- 
stances, however, are not uncommon of pronounced diabetes in which the 
thirst is not excessive; but in such cases the amount of urine passed is 
never large. The thirst is most intense an hour or two after meals. As 
a rule, the digestion is good and the appetite inordinate. The condition 
is sometimes termed bulimia or polyphagia. Lumbar pain is common. 

The tongue is usually dry, red, and glazed, and the saliva scanty. The 
gums may become swollen, and in the later stages aphthous stomatitis is 
common. Constipation is the rule. 

In spite of the enormous amount of food consumed a patient may be- 
come rapidly emaciated. This loss of flesh bears some ratio to the poly- 
uria, and when, under suitable diet, the sugar is reduced, the patient may 
quickly gain in flesh. The skin is dry and harsh, and sweating rarely occurs, 
except when phthisis coexists. Drenching sweats have been known to alter- 
nate with excessive polyuria. The temperature is often subnormal; the 
pulse is usually frequent, and the tension increased. Many diabetics, how- 
ever, do not show marked emaciation. Patients past the middle period 
of life may have the disease for years without much disturbance of the 
health, and may remain well nourished. These are the cases of the diabete 
gras in contradistinction to diabete maigre. 

The Urine. — The amount varies from 6 or 8 pints in mild cases to 30 
or 40 pints in very severe cases. In rare instances the quantity of urine 
is not much increased. Under strict diet the amount is much lessened, and 
in intercurrent febrile affections it may be reduced to normal. The specific 
gravity is high, ranging from 1.025 to 1.045; but in exceptional cases it 
may be low, 1.013 to 1.020. The highest specific gravity recorded, so far 
as I know, is by Trousseau — 1.074. Very high specific gravities — 1.070 + 
— suggest fraud. The urine is pale in color, almost like water, and has a 
sweetish odor and a distinctly sweetish taste. The reaction is acid. Sugar 
is present in varying amounts. In mild cases it does not exceed 1-| or 2 per 
cent, but it may reach from 5 to 10 per cent. The total amount excreted 
in the twenty-four hours may range from 10 to 20 ounces, and in exceptional 
cases from 1 to 2 pounds. The following are the most satisfactory tests: 

Fehling's Test. — The solution consists of sulphate of copper (grs. 90 J), 
neutral tartrate of potassium (grs. 364), solution of caustic soda (fl. ozs. 4), 
and distilled water to make up 6 ounces. Put a drachm of this in a test- 
tube and boil (to test the reagent); add an equal quantity of urine and boil 
again, when, if sugar is present, the yellow suboxide of copper is thrown 
down. The solution must be freshly prepared, as it is apt to decompose. 

Trommer's Test. — To a drachm of urine in a test-tube add a few drops 
of a dilute sulphate-of-copper solution and then as much liquor potasses 
as urine. On boiling, the copper is reduced if sugar be present, forming 
the yellow or orange-red suboxide. There are certain fallacies in the copper 



424: 



CONSTITUTIONAL DISEASES. 



tests. Thus, a substance called glycuronic acid is met with in the urine 
after the use of certain drugs — chloral, phenacetin, morphia, chloroform, 
etc. — which reduces copper. Homogentisinic, uroleucinic, and glycosuric 
acids, which are held to be the cause of alcaptonuria, may also prove a 
source of error (see Alcaptonuria, by T. B. Futcher, N. Y. Med. Jour., 
1898, i). 

Fermentation Test. — This is free from all doubt. Place a small frag- 
ment of yeast in a test-tube full of urine, which is then inverted over a 
glass vessel containing the same fluid. If sugar is present, fermentation 
goes on with the formation of carbon dioxide, which accumulates in the 
upper part of the tube and gradually expels the urine. In doubtful cases 
a control test should always be used. For laboratory work the polariscope 
is of great value. 

Of other ingredients in the urine, the urea is increased, the uric acid 
does not show special changes, and the phosphates may be greatly in ex- 
cess. The calcium salts are markedly increased. The same holds true 
for the ammonia in all severe cases, and particularly in diabetic coma. 
Ealfe has described a great increase in the phosphates, and in some of 
these cases, with an excessive excretion, the symptoms may be very simi- 
lar to those of diabetes, though the sugar may not be constantly present. 
The term phosphatic diabetes has sometimes been applied to them. 
Acetone and acetone-forming substances are not infrequently present. 
Lieben's test is as follows: The urine is distilled and a few cubic centimetres 
of the distillate are rendered alkaline with liquor potassae. A few drops of 
Lugol's solution are then added, when, if acetone be present, the distillate 
assumes a turbid yellow color, due to the formation of iodoform, which is 
recognized by its odor and by the formation of minute hexagonal and 
stellate crystals. Diacetic acid is sometimes present, and may be recognized 
from the fact that a solution of the chloride of iron yields a beautiful 
Bordeaux-red color. Other substances, as formic, carbolic, and salicylic 
acids, give the same reaction in both fresh and previously boiled urine, 
while diacetic acid does not give the reaction in urine previously boiled. 
In testing for diacetic acid perfectly fresh urine should be used, as it 
rapidly becomes broken up into acetone and carbonic acid. /3-oxybutyric 
acid, the recognized cause of coma, should be tested for in all severe cases.. 
As it is lasvo-rotatory, its presence is indicated by lsevo-rotation in com- 
pletely fermented urine, as well as by the greater percentage of sugar 
demonstrable with Fehling's than with the polariscopic method. 

Bremer finds that diabetic urine has the power of dissolving gentian 
violet, whereas normal urine fails to do so. Unfortunately, the urine in 
diabetes insipidus and in certain forms of polyuria reacts similarly. Froh- 
lich has recently devised a test based on the fact that diabetic urine has the 
property of decolorizing solutions of methylene blue. 

Glycogen has also been described as present in the urine. 

Albumin is not infrequent. It occurred in nearly 37 per cent of the 
examinations made by Lippman at Carlsbad. 

Pneumaturia, the formation of gas in the urine, due to fermentative 
processes in the bladder, is occasionally met with. 



DIABETES MELLITUS. 



425 



Fat may be passed in the urine in the form of a fine emulsion (lipuria). 

Diabetes in Children, — Stern has analyzed 117 eases in children. They 
usually occur among the better classes. Six were under one year of age. 
Hereditary influences were marked. The course of the disease is, as a rule, 
much more rapid than in adults. The shortest duration was two days. In 
7 cases it did not last a month. One case is mentioned of a child apparently 
born with the glycosuria, who recovered in eight months. 

Complications. — (a) Cutaneous. — Boils and carbuncles are extremely 
common. Painful onychia may occur. Eczema is also met with, and at 
times an intolerable itching. In women the irritation of the urine may 
cause the most intense pruritus pudendi, and in men a balanitis. Earer 
affections are xanthoma and purpura. Gangrene is not uncommon, and 
is associated usually with arterio-sclerosis. William Hunt has analyzed 
64 cases. In 50 the localities were as follows: Feet and legs, 37; thigh and 
buttock, 2; nucha, 2; external genitals, 1; lungs, 3; fingers, 3; back, 1; 
eyes, 1. Perforating ulcer of the foot may occur. Bronzing of the skin 
(diabete bronze) occurs in certain cases of diabetes in which the latter de- 
velops as a late event in the disease known as hemochromatosis, which is 
further characterized by pigmentary cirrhosis of the liver and pancreas. 
With the onset of severe complications the tolerance of the carbohydrates 
is much increased. Profuse sweats may occur. 

(b) Pulmonary. — The patients are not infrequently carried off by acute 
'pneumonia, which may be lobar or lobular. Gangrene is very apt to super- 
vene, but the breath does not necessarily have the foul odor of ordinary 
gangrene. 

Tuberculous broncho-pneumonia is very common. It was formerly 
thought, from its rapid course and the limitation of the disease to the lung, 
that this was not a true tuberculous affection; but in the cases which have 
come under my notice the bacilli have been present, and the condition is 
now generally regarded as tuberculous. 

(c) Renal. — Albuminuria is a tolerably frequent complication. The 
amount varies greatly, and, when slight, does not seem to be of much mo- 
ment. (Edema of the feet and ankles is not an infrequent symptom. Gen- 
eral anasarca is rare, however, owing to the marked polyuria. It was pres- 
ent in a marked degree in one of my 156 cases. It is sometimes associated 
with arterio-sclerosis. It occasionally precedes the development of the dia- 
betic coma. Occasionally cystitis develops. 

(d) Nervous System. — (1) Diabetic coma, first studied by Kussmaul, 
comes on in a considerable proportion of all cases, particularly in the young. 
Stephen Mackenzie states that of the fatal cases of diabetes at the London 
Hospital, nil under the age of twenty-five, with but one exception, had died 
in coma. In Naunyn's 44 fatal cases it occurred in 12. It preceded death 
in 28 of Williamson's 40 cases. It occurred in 15 of the 27 fatal cases in my 
series. Frerichs recognized three groups of cases: (a) Those in which after 
exertion the patients were suddenly attacked with weakness, S3^ncope, som- 
nolence, and gradually deepening unconsciousness; death occurring in a few 
hours. Cases with preliminary gastric disturbance, such as nausea and 
vomiting, or some local affection, as pharyngitis, phlegmon, or a pulmonary 



426 



CONSTITUTIONAL DISEASES. 



complication. In such cases the attack begins with headache, delirium, 
great distress, and dyspnoea, affecting both inspiration and expiration, a 
condition called by Kussmaul air-hunger. Cyanosis may or may not be 
present. If it is, the pulse becomes rapid and weak and the patient grad- 
ually sinks into coma; the attack lasting from one to five days. There 
may be a very heavy sweetish odor of the breath, due to the presence of 
acetone, (y) Cases in which, without any previous dyspnoea or distress, the 
patient is attacked with headache and a feeling of intoxication, and rapidly 
falls into a deep and fatal coma. There are atypical cases in which the coma 
is due to uraemia, to apoplexy, or to meningitis. 

There has been much dispute as to the nature of these symptoms, but 
clinical laboratory investigations have practically afforded a satisfactory 
explanation. For years the coma symptoms were ascribed to the toxic- 
effects of acetone and later to those of diacetic acid. Experimental work, 
however, showed that these views were incorrect. The almost universal 
opinion now is that the coma is due to an acid intoxication, or, as Naunyn 
terms it, an acidosis. The offending agent is believed to be y8-ox}^butyric 
acid, which accumulates in the tissues and circulating blood in enormous 
quantities, and is eliminated in the urine in combination with various base- 
forming elements, but never free. In 1884 Stadelmann, Kiilz, and Min- 
kowski almost simultaneously found this acid in the urine of patients with 
diabetic coma. Subsequent researches, particularly those published from 
Naunyn's clinic, have fully confirmed these results, and it is now almost 
universally accepted that /?-oxybutyric acid is the cause of diabetic coma. 
The amount of the acid excreted in the twenty-four hours may be enormous. 
Kiilz found in 3 cases 67, 100, and 226 grammes respectively. Magnus- 
Levy has estimated that from 100 to 200 grammes are often contained in 
the tissues of fatal cases. This author is of the belief that the /?-oxybu- 
tyric acid is derived from the fats of the body, whereas most observers, in- 
cluding JNTaunyn, trace it to the disintegration of the tissue albumins. Ace- 
tone and diacetic acid are derivative products of the /?-oxybutyric acid. 

Saunders and Hamilton have described cases in which the lung cap- 
illaries were blocked with fat. They attributed the symptoms to fat em- 
bolism, but there are many cases on record in which this condition was not 
found, though lipsemia is by no means infrequent in diabetes. 

Albuminuria frequently precedes or accompanies the attack, and numer- 
ous small, short, hyaline, and finely granular casts are demonstrable. 

(2) Peripheral Neuritis. — The neuralgias, numbness, and tingling, which 
are not uncommon symptoms in diabetes, are probably minor neuritic 
manifestations. Herpes zoster may occur. Perforating ulcer of the foot 
may develop. 

Diabetic Tabes (so called). — This is a peripheral neuritis, characterized 
by lightning pains in the legs, loss of knee-jerk — which may occur with- 
out the other symptoms — and a loss of power in the extensors of the feet. 
The gait is the characteristic steppage, as in arsenical, alcoholic, and other 
forms of neuritic paralysis. Charcot states that there may be atrophy of 
the optic nerves. Changes in the posterior columns of the cord have been 
found by Williamson and others. 



DIABETES MELLITUS. 



427 



Diabetic Paraplegia. — This is also in all probability due to neuritis. 
There are cases in which power has been lost in both arms and legs. 

(3) Mental Symptoms. — The patients are often morose, and there is a 
strong tendency to become hypochondriacal. General paralysis has been 
known to develop. Some patients display an extraordinary degree of rest- 
lessness and anxiety. 

(4) Special Senses. — Cataract is liable to occur, and may develop with 
rapidity in young persons. Diabetic retinitis closely resembles the albu- 
minuric form. Haemorrhages are common. Sudden amaurosis, similar 
to that which occurs in uraemia, may occur. Paralysis of the muscles of 
accommodation may be present; and lastly, atrophy of the optic nerves. 
Aural symptoms may come on with great rapidity, either an otitis media, 
or in some instances inflammation of the mastoid cells. 

(5) Sexual Function. — Impotence is common, and may be an early 
symptom. Conception is rare; if it occurs, abortion is apt to follow. A 
diabetic mother may bear a healthy child; there is no known instance of a 
diabetic mother bearing a diabetic child. The course of the disease is 
usually aggravated after delivery. 

Course. — In children the disease is rapidly progressive, and may prove 
fatal in a few days. It may be stated, as a general rule, that the older the 
patient at the time of onset the slower the course. Cases without hereditary 
influences are the most favorable. In stout, elderly men diabetes is a much 
more hopeful disease than it is in thin persons. Middle-aged patients may 
live for many years, and persons are met with who have had the disease 
for ten, twelve, or even fifteen years. 

Diagnosis. — As stated in the definition, for a case to be considered 
diabetes the sugar eliminated in the urine must be grape sugar, it should 
be present for weeks, months, or years, and the excretion of sugar must 
take place after the ingestion of moderate amounts of carbohydrates. As 
a rule, there is no difficulty in determining the presence of diabetes. The 
urine tests already given are distinctive. 

Bremer's Blood Test. — This author claims that he is able to make a diag- 
nosis of diabetes from the examination of a drop of the patient's blood, de- 
pending on the fact that it reacts differently from normal blood to various 
aniline dyes. 

His latest published method is briefly as follows: Bather thick smears 
of suspected and normal blood are made on ordinary microscopic slides. 
They are then heated in a thermostat up to 135° C, and when sufficiently 
cooled are stained in a one-per-cent aqueous solution of Congo-red for one 
and a half to two minutes. Slides of the non-diabetic and diabetic blood 
are placed back to back, so that each will be exposed to the same conditions. 
The excess of the stain is washed off, and if the suspected patient has dia- 
betes the blood will be unstained, whereas the normal blood takes a dis- 
tinct Coniro-rcd stain. Bremer obtains this reaction in the prediabetic 
stage, and ;ilso in the intervals when the patient's urine is temporarily free 
from siifrar. TTe thinks the reaction is due to a qualitative change in the 
haemoglobin of the red blood-cells, and not to an excess of grape sugar in 
the blood. In a number of cases in my wards, in which the test has been 



428 



CONSTITUTIONAL DISEASES. 



performed, the reaction has been repeatedly obtained, but it was not pos- 
sible to fully confirm Bremer's statement that the reaction was also present 
when the urine was temporarily free from sugar. According to E. T. Wil- 
liamson, diabetic blood has the power to decolorize weak alkaline solutions 
of methylene blue to a yellowish-green or yellow color. He has devised a 
blood test for diabetes, using definite proportions of blood and the reagent. 
Williamson has obtained the reaction in every one of 11 cases of diabetes 
in which the test was tried, but failed to get it in a single instance in the 
blood of 100 non-diabetic cases. He is inclined to the view that the reaction 
is due to an excess of sugar in the blood. The reaction was obtained by 
Futcher in 7 cases in which it was tried in my wards (Phila. Med. Journal, 
February 12, 1898). 

Deception may be practised. A young girl under my care had urine 
with a specific gravity of 1.065. The reactions were for cane sugar. There 
is one case in the literature in which, after the cane-sugar fraud was de- 
tected, the woman bought grape sugar and put it into her bladder! 

Prognosis. — In true diabetes instances of cure are rare. On the 
other hand, the transient or intermittent glycosuria, met with in stout 
overfeeders, or in persons who have undergone a severe mental strain, is 
very amenable to treatment. Not a few of the cases of reputed cures be- 
long to this division. Practically, in cases under forty years of age the 
outlook is bad; in older persons the disease is less serious and much more 
amenable to treatment. It is a good plan at the outset to determine whether 
the urine of a patient contains sugar or not on a diet absolutely free from 
carbohydrates. In mild cases the sugar disappears; in the severer cases it 
continues to be formed from the proteids. 

Treatment. — In families with a marked predisposition to the disease 
the use of starchy and saccharine articles of diet should be restricted. 

The personal hygiene of a diabetic patient is of the first importance. 
Sources of worry should be avoided, and he should lead an even, quiet life, 
if possible in an equable climate. Flannel or silk should be worn next to 
the skin, and the greatest care should be taken to promote its action. A 
lukewarm, or if tolerably robust, a cold bath, should be taken every day. 
An occasional Turkish bath is useful. Systematic, moderate exercise should 
be taken. When this is not feasible, massage should be given. It is well 
to study accurately the dietetic capabilities of each case. 

Diet. — Our injunctions to-day are those of Sydenham: "Let the pa- 
tient eat food of easy digestion, such as veal, mutton, and the like, and ab- 
stain from all sorts of fruit and garden stuff." 

Diabetic patients admitted to the medical wards of the Johns Hopkins 
Hospital are kept for three or four days on the ordinary ward diet, which 
contains moderate amounts of carbohydrates, in order to ascertain the 
amount of sugar excretion. For two days more the starches are gradually 
cut off. They are then placed on the following standard non-carbohydrate 
diet, arranged from a list recommended by von Noorden: 

Breakfast: 7.30, 200 cc. (§ vi) of tea or coffee; 150 grammes (g iv) of 
beefsteak, mutton-chops without bone, or boiled ham; one or two eggs. 

Lunch: 12.30, 200 grammes (5 vi) cold roast beef; 60 grammes (5 ij) 



DIABETES MELL1TUS. 



429 



celery, fresh cucumbers or tomatoes with vinegar, olive oil, pepper and salt 
to taste; 20 cc. (5 v) whisky with 400 cc. (§ xiij) water; 60 cc. (5 ij) coffee, 
without milk or sugar. 

Dinner: 6 p.m., 200 cc. clear bouillon; 250 grammes (5 viiss) roast 
beef; 10 grammes (3 iiss) butter; 80 grammes (§ ij) green salad, with 10 
grammes (3 iiss) vinegar and 20 grammes (3 v) olive oil, or three table- 
spoonfuls of some well-cooked green vegetable; three sardines a Fhuile; 
20 cc. (3v) whisky, with 400 cc. (§ xiij) water. 

Supper: 9 p. m., two eggs (raw or cooked); 400 cc. (5 xiij) water. 

This diet contains about 200 grammes of albumin and about 135 
grammes of fat. The effect of the diet on the sugar excretion is remark- 
able. In many cases there is an entire disappearance of the sugar from 
the urine in three or four days. Chart XV shows very graphically the 
remarkable drop in the sugar excretion for the first twenty-four hours in 
a case placed on the standard diet. The sugar failed, however, in this par- 
ticular case to entirely disappear from the urine except on one day, al- 
though he was kept on the diet for over two months. In cases in which 
the urine becomes free from sugar gradually increasing quantities of starch 
up to 20, 50, and 100 grammes are added daily. White bread contains 
fifty-five per cent of starch. The effect of the non-carbohydrate diet, ac- 
cording to von Noorden, is to improve the metabolic functions so that the 
system can warehouse considerable quantities of carbohydrates without 
sugar appearing in the urine. He advises that patients should return to 
the strict non-carbohydrate regimen at intervals of three or four months, 
so as to increase their power of warehousing carbohydrates. 

• In cases in which a standard diet is not ordered it is well to begin cut- 
ting off article by article until the sugar disappears from the urine. Within 
a month or two the patient may be allowed a more liberal diet, testing the 
different kinds of food. 

The following is a list of articles which diabetic patients may take: 

Liquids: Soups — ox-tail, turtle, bouillon, and other clear soups. Lem- 
onade, coffe.fi, tea, chocolate, and cocoa; these to be taken without sugar, 
but they may be sweetened with saccharin. Potash or soda water, and 
Apollinaris, or the Saratoga-Vichy, and milk in moderation, may be used. 

Of animal food: Fish of all sorts, including crabs, lobsters, and oysters; 
salt and fresh butcher's meat (with the exception of liver), poultry, and 
game. Eggs, butter, buttermilk, curds, and cream cheese. 

Of bread: Gluten and bran bread, and almond and cocoanut biscuits. 

Of vegetables: Lettuce, tomatoes, spinach, chicory, sorrel, radishes, 
asparagus, water-cress, mustard and cress, cucumbers, celery, and endives. 
Pickles of various sorts. 

Fruits: Lemons and oranges. Currants, plums, cherries, pears, apples 
(tart), melons, raspberries and strawberries may be taken in moderation. 
Nuts are, as a rule, allowable. 

Among prohibited articles are the following: Thick soups and liver. 

Ordinary bread of all sorts (in quantity), rye, wheaten, brown, or white. 
All farinaceous preparations, such as hominy, rice, tapioca, semolina, arrow- 
root, sago, and vermicelli. 



430 CONSTITUTIONAL DISEASES. 

Of vegetables: Potatoes, turnips, parsnips, squashes, vegetable-mar- 
rows of all kinds, beets, corn, artichokes. 

Of liquids: Beer, sparkling wine of all sorts, and the sweet aerated 
drinks. 

In feeding a diabetic patient one of the greatest difficulties is in 
arranging a substitute for bread. Of the gluten foods, many are very 
unpalatable; others are frauds. 



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Black, Sugar in grammes Red, Urine in c c 



Chart XV. — Illustrating influence of diet on sugar and amount of urine. 



A good gluten flour is made by the Battle Creek Sanitarium Company, 
Michigan. Other substitutes are the 'almond food, the Aleuronat bread, 
and soya bread, but these and other substitutes are not satisfactory as a 
rule. For sweetening purposes saccharin may be used, of which tablets are 
prepared. 

Medicinal Treatment. — This is most unsatisfactory, and no one drug 

appears to have a directly curative influence. Opium alone stands the 
test of experience as a remedy capable of limiting the progress of the dis- 
ease. Diabetic patients seem to have a special tolerance for this drug. 



DIABETES MELLITUS. 



431 



Codeia is preferred by Pavy, and has the advantage of being less consti- 
pating than morphia. A patient may begin with half a grain three times 
a day, which may be gradually increased to 6 or 8 grains in the twenty- 
four hours. Not much effect is noticed unless the patient is on a rigid diet. 
When the sugar is reduced to a minimum, or is absent, the opium should 
be gradually withdrawn. The patients not only bear well these large doses 
of the drug, but they stand its gradual reduction. Potassium bromide is 
often a useful adjunct. The arsenite of bromine, a solution of arsenious 
acid with bromine in glycerin (dose, 3 to 5 minims after meals), has been 
very highly recommended, but it is by no means so certain as opium. 
Arsenic alone may be used. Antipyrin may be given in doses of 10 grains 
three times a day, and in cases with a marked neurotic constitution is some- 
times satisfactory. The salicylates, iodoform, nitroglycerin, jambul, the 
lithium salts, strychnine, creasote, and lactic acid have been employed. 

Preparations of the pancreas (glycerin extracts of the dried and fresh 
gland) have been used in the hope that they would supply the internal secre- 
tion necessary to normal sugar metabolism. The success has not, however, 
been in any way comparable with that obtained with the thyroid extract in 
myxoedema. Lepine has isolated a glycolytic ferment from the pancreas 
and also from the malt diastase, and has used it with some success in 4 cases. 

Of the complications, the pruritus and eczema are best treated by cool- 
ing lotions of boric acid or hyposulphite of soda (1 ounce; water, 1 quart), 
or the use of ichthyol and lanolin ointment. 

In the thin, nervous cases the bowels should be kept open and the urine 
tested at short intervals for acetone and diacetic acid — the derivatives of 
0-oxy-butyric acid. 

The coma is an almost hopeless complication. Inhalations of oxygen 
have been recommended. The use of bicarbonate of soda in very large doses 
is recommended to neutralize the acid intoxication. It may be used intra- 
venously; as much as 80 grammes have been injected. This treatment was 
first recommended by Stadelmann, and has undoubtedly given the best re- 
sults. Naunyn and Magnus-Levy report cases of recovery from coma by 
its use. I have had one recovery. The sodium bicarbonate should be 
pushed until the urine is alkaline. As much as 100 grammes should be 
given daily. All diabetics with a marked diacetic acid reaction in the urine 
should be placed on sodium bicarbonate. Next to the antacid treatment, 
subcutaneous or intravenous injections of normal salt solution have given 
the best results. The improvement, unfortunately, is only temporary with 
this line of treatment. Reynolds published 2 cases of recovery after the 
administration of a dose of castor oil, followed by 30 to 60 grains of citrate 
of potassium every hour in copious draughts of water. The bowels of a 
diabetic patient should be kept acting freely, as constipation is believed 
to predispose to the development of coma. 

♦ 



27 



432 



CONSTITUTIONAL DISEASES. 



VI. DIABETES INSIPIDUS. 

Definition. — A chronic affection characterized hy the passage of large 
quantities of normal urine of low specific gravity. 

The condition is to be distinguished from diuresis or polyuria, which 
is a frequent symptom in hysteria, in Bright's disease, and occasionally 
in cerebral or other affections. Willis, in 1674, first recognized the distinc- 
tion between a saccharine and non-saccharine form of diabetes. 

Etiology. — The disease is most common in young persons. Of the 
85 cases collected by Strauss, 9 were under five years; 12 between five and 
ten years; 36 between ten and twenty-five years. Males are more fre- 
quently attacked than females. The affection may be congenital. A hered- 
itary tendency has been noted in many instances, the most extraordinary 
of which has been reported by Weil. Of 91 members in four generations, 
23 had persistent polyuria without any deterioration in health. Injury to 
the nervous system has been present in certain cases, and the disease has 
followed sunstroke, or a violent emotion, such as fright. Traumatism 
has occasionally been the exciting cause. The injury may have been to 
the head, but in other cases it has been to the trunk or to the limbs. Trous- 
seau stated that the parents of children with diabetes insipidus frequently 
have glycosuria or albuminuria. Ealfe stated that malnutrition is an im- 
portant predisposing factor in children. The disease has followed rapidly 
the copious drinking of cold water, or a drinking-bout; or has set in during 
the convalescence from an acute disease. Tumors of the brain and lesions 
of the medulla have been met with in a few instances. Cases of polyuria 
have been accompanied by paralysis of the sixth nerve. Maguire has seen an 
instance after meningitis in which paralysis of the sixth pair occurred with it. 
Bernard, it will be remembered, discovered a spot in the floor of the fourth 
ventricle of animals, irritation of which produced polyuria. Lesions of 
the organs of the abdomen may be associated with an excessive flow of 
urine, which, however, should not be regarded as true diabetes insipidus. 
Dickenson mentions 'its occurrence in abdominal tumors; Ealfe, in ab- 
dominal aneurism. I have noted it in several cases of tuberculous peri- 
tonitis. There have been only 3 cases of diabetes insipidus out of a total 
of 239,000 patients treated at the Johns Hopkins Hospital and Dispensary. 

The nature of the disease is unknown. It is, doubtless, of nervous 
origin. The most reasonable view is that it results from a vaso-motor dis- 
turbance of the renal vessels, due either to local irritation, as in a case of 
abdominal tumor, to central disturbance in cases of brain-lesion, or to 
functional irritation of the centre in the medulla, giving rise to continuous 
renal congestion. 

Morbid Anatomy. — There are no constant anatomical lesions. The 
kidneys have been found* enlarged and congested. The bladder has been 
found hypertrophied. Dilatation of the ureters and of the pelves of the 
kidneys has been present. Death has not infrequently resulted from chronic 
pulmonary disease. Very varied lesions have been met with in the nervous 
system. 



DIABETES INSIPIDUS. 



433 



Symptoms. — The disease may come on rapidly, as after a fright or 
an injury. More commonly it develops slowly. According to Kalfe, the 
patients often complain in the early stages of severe racking pains in the 
lumbar region shooting down the thighs. A copious secretion of urine, 
with increased thirst, are the prominent features of the disease. The 
amount of urine in the twenty-four hours may range from 20 to 40 pints, 
or even more. Trousseau speaks of a patient who consumed 50 pints of 
fluid daily and passed about 56 pints of urine in the twenty-four hours. 
The specific gravity is low, 1.001 to 1.005; the color is extremely pale and 
watery. The total solid constituents may not be reduced. The amount of 
urea has sometimes been found in excess. Abnormal ingredients are rare. 
Muscle-sugar, inosite, has been occasionally found. Albumin is rare. 
Traces of sugar have been met with. Naturally, with the passage of such 
enormous quantities of urine, there is a proportionate thirst, and the only 
inconvenience of the disease is the necessity for frequent micturition and 
frequent drinking. The appetite is usually good, rarely excessive as in 
diabetes mellitus; but Trousseau tells of the terror inspired by one of his 
patients in the keepers of those eating-houses where bread was allowed with- 
out extra charge to the extent of each customer's wishes, and says that he 
was presented with money to prevent him coming back to dine. The 
patients may be well nourished and healthy-looking. The disease in many 
instances does not appear to interfere in any way with the general health. 
The perspiration is naturally slight and the skin is harsh. The amount 
of saliva is small and the mouth usually dry. Cases have been described 
in which the tolerance of alcohol has been remarkable, and patients have 
been known to take a couple of pints of brandy, or a dozen or more bottles 
of wine, in the day. 

The course depends entirely upon the nature of the primary trouble. 
Sometimes, with organic disease, either cerebral or abdominal, the general 
health is much impaired; the patient becomes thin, and rapidly loses 
strength. In the essential or idiopathic cases, good health may be main- 
tained for an indefinite period, and the affection has been known to persist 
for fifty years. Death usually results from some intercurrent affection. 
Spontaneous cure may take place. 

Diagnosis. — A low specific gravity and the absence of sugar in the 
urine distinguish the disease from diabetes mellitus. Hysterical polyuria 
may sometimes simulate it very closely. The amount of urine excreted 
may be enormous, and only the development of other hysterical manifesta- 
tions may enable the diagnosis to be made. This condition is, however, 
always transitory. 

In certain cases of chronic Bright's disease a very large amount of 
urine of low specific gravity may be passed, but the presence of albumin 
and of hyaline casts, and the existence of heightened arterial tension, stiff 
vessels, and hypertrophied left ventricle make the diagnosis easy. 

Treatment. — The treatment is not satisfactory. No attempt should 
be made to reduce the amount of liquid. Opium is highly recommended, 
but is of doubtful service. The preparations of valerian may be tried; 
either the powdered root, beginning with 5 grains three times a day, and 



434 



CONSTITUTIONAL DISEASES. 



increasing until 2 drachms are taken in the day, or the valerianate of zinc, 
in 15-grain doses, gradually increased to 30 grains, three times a day. Ergot, 
ergotin, antipyrin, the salicylates, arsenic, strychnine, turpentine, and the 
bromides have been recommended. Electricity may be used. 



VII. RICKETS (Rhachitis). 

Definition. — A disease of infants, characterized by impaired nutrition 
of the entire body and alterations in the growing bones. 

Glisson, the anatomist of the liver, accurately described the disease in 
the seventeenth century. The name is derived from the old English word 
wrickken, to twist. Glisson suggested to change the name to rhachitis, from 
the Greek, pax ts > the spine, as it was one of the first parts affected, and 
also from the similarity in the sound to rickets. 

Etiology. — Eickets exists in all parts of the world, but is particularly 
marked among the poor of the larger cities, who are badly housed and ill 
fed. It is much more common in Europe than in America. In Vienna and 
London from 50 to 80 per cent of all the children at the clinics present 
signs of rickets. It is a comparatively rare disease in Canada. In the cities 
of this continent it is very prevalent, particularly among the children of 
the negro and of the Italian races. Want of sunlight and impure air are 
important factors. Prolonged lactation and suckling the child during preg- 
nancy are accessory influences in some cases. 

There is no evidence that the disease is hereditary. 

Eickets affects male and female children equally. It is a disease of the 
first and second years of life, rarely beginning before the sixth month. 
Jenner has described a late rickets, in which form the disease may not ap- 
pear until the ninth or even until the twelfth year. It has been held that 
rickets is only a manifestation of congenital syphilis (Parrot), but this is 
certainly not correct. Syphilitic bones rarely, if ever, present the spongy 
tissue peculiar to rickets, and rachitic bones never show the multiple oste- 
ophytes of syphilis. " Syphilis modifies rickets; it does not create it " 
(Cheadle). A faulty diet is the essential factor in the production of the 
disease. Like scurvy, rickets may be found in the families of the wealthy 
under perfect hygienic conditions. It is most common in children fed on 
condensed milk, the various proprietary foods, cow's milk, and food rich 
in starches. " An analysis of the foods on which rickets is most frequently 
and certainly produced shows invariably a deficiency in two of the chief 
elements so plentiful in the standard food of young animals — namely, ani- 
mal fat and proteid " (Cheadle). Bland Sutton's interesting experiment 
with the lion's cubs at the " Zoo " illustrates this point. When milk, 
pounded bones, and cod-liver oil were added to the meat diet the rickets 
disappeared, and for the first time in the history of the society the cubs 
were reared. Associated with the defect in food is a lack of proper assimila- 
tion of the lime salts. 

Morbid Anatomy. — The Vones show the most important changes, 
particularly the ends of the long bones and the ribs. Between the shaft 



RICKETS. 



435 



and epiphyses a slight bulging is apparent, and on section the zone of pro- 
liferation, which normally is represented by two narrow bands, is greatly 
thickened, bluish in color, more irregular in outline, and very much softer. 
The width of this cushion of cartilage varies from 5 to 15 mm. The line 
of ossification is also irregular and more spongy and vascular than normal. 
The periosteum strips off very readily from the shaft, and beneath it there 
may be a spongioid tissue not unlike decalcified bone. The practical out- 
come of these changes is a delay in, and imperfect performance of, the 
ossification, so that the bone has neither the natural rate of growth nor the 
normal firmness. In the cranium there may be large areas, particularly in 
the parieto-occipital region, in which the ossification is delayed, producing 
the so-called cranio-tabes, so that the bone yields readily to pressure with 
the finger. There are localized depressed spots of atrophy, which, on 
pressure, give the so-called " parchment crackling." Flat hyperostoses de- 
velop from the outer table, particularly on the frontal and parietal bones, 
and produce the characteristic broad forehead with prominent frontal emi- 
nences, a condition sometimes mistaken for hydrocephalus. 

Kassowitz, the leading authority on the anatomy of rickets, regards 
the hyperemia of the periosteum, the marrow, the cartilage, and of the 
bone itself as the primary lesion, out of which all the others develop. This 
disturbs the normal development of the growing bone and excites changes 
in that already formed. The cartilage cells in consequence proliferate, 
the matrix is softer, and as a result the bone which is formed from this 
unhealthy cartilage is lacking in firmness and solidity. In the bone already 
formed this excessive vascularity exaggerates the normal processes of ab- 
sorption, so that the relation between removal and deposition is disturbed, 
absorption taking place too rapidly. The new material is poor in lime salts. 
Kassowitz has proved experimentally that hyperemia of bone results in 
defective deposition of lime salts. It is interesting to note that Glisson 
attributed rickets to disturbed nutrition by arterial blood, and believed 
the changes in the long bones to be due to excessive vascularity. 

The chemical analysis of rickety bones shows a marked diminution in 
the calcareous salts, which may be as low as 25 or 35 per cent. 

The liver and spleen are usually enlarged, and sometimes the mesen- 
teric glands. As Gee suggests, these conditions probably result from the 
general state of the health associated with rickets. Beneke has described 
a relative increase in the size of the arteries in rickets. 

Symptoms. — The disease comes on insidiously about the period of 
dentition, before the child begins to walk. Mild grades of it are often over- 
looked in the families of the well-to-do. In many cases digestive disturb- 
ances precede the appearance of the characteristic lesions, and the nutrition 
of the child is markedly impaired. There is usually slight fever, the child 
is irritable and restless, and sleeps badly. If he has already walked, he 
now shows a marked disinclination to do so, and seems feeble and unsteady 
in his gait. Sir William Jenner has called attention to three general symp- 
toms of great importance: First, a diffuse soreness of the body, so that 
the child cries when an attempt is made to move it, and prefers to keep 
perfectly still. This is often a marked and suggestive symptom. Secondly, 



436 



CONSTITUTIONAL DISEASES. 



slight fever (100° to 101. 5°), with nocturnal restlessness, and a tenden- 
cy to throw off the bedclothes. This may be partly due to the fact 
that the general sensitiveness is such that even their weight may be dis- 
tressing. And, thirdly, profuse sweating, particularly about the head 
and neck, so that in the morning the pillow is found soaked with perspi- 
ration. 

The tissues become soft and flabby;' the skin is pale; and from a 
healthy, plump condition, the child becomes puny and feeble. The mus- 
cular weakness may be marked, particularly in the legs, and paralysis may 
be suspected. This so-called pseudo-paresis of rickets results in part from 
the flabby, weak condition of the legs and in part from the pain associated 
with the movements. Coincident with, or following closely upon, the gen- 
eral symptoms the characteristic skeletal lesions are observed. Among 
the first of these to appear are the changes in the ribs, at the junction of 
the bone with the cartilage, forming the so-called rickety rosary. When 
the child is thin these nodules may be distinctly seen, and in any case can 
be easily made out by touch. They very rarely appear before the third 
month. They may increase in size up to the second year, and are rarely 
seen after the fifth year. The thorax undergoes important changes. Just 
outside the junction of the cartilages with the ribs there is an oblique, 
shallow depression extending downward and outward. A transverse curve, 
sometimes called Harrison's groove, passes outward from the level of the 
ensiform cartilage toward the axilla and may be deepened at each inspira- 
tion. It is rendered more prominent by the eversion and prominence of 
the costal border. The sternum projects, particularly in its lower half, 
forming the so-called pigeon or chicken breast. These changes in the 
thorax are not peculiar, however, to rickets, and are much more commonly 
associated with hypertrophy of the tonsils, or any trouble which interferes 
with the free entrance of air into the lungs. The spine is often curved 
posteriorly, the processes are prominent; lateral curvature is not so 
common. 

The head of a rickety child usually looks large in proportion both to 
the body and the face, and the fontanelles remain open for a long time. 
There are areas, particularly in the parietooccipital regions, in which ossi- 
fication is imperfect; and the bone may yield to the pressure of the finger, 
a condition to which the term cranio-tabes has been given. The relation 
of this condition to rickets is still somewhat doubtful, as it is very often 
associated with syphilis — in 47 of 100 cases studied by George Carpenter. 
Coincidently with this, hyperplasia proceeds in the frontal and parietal 
eminences, so that these portions of the skull increase in thickness, and 
may form irregular bosses. In one type the skull may be large and elon- 
gated, with the top considerably flattened. In another, and perhaps more 
common case, the shape of the skull, when seen from above, is rectangular 
— the caput quadratum. The skull looks large in proportion to the face. 
The forehead is broad and square, and the frontal eminences marked. The 
anterior fontanelle is late in closing and may remain open until the third 
or fourth year. The skin is thin, the veins are full and prominent, and the 
hair is often rubbed from the back of the skull. In contradistinction to the 



RICKETS. 



437 



cranio-tabes is the condition of cranio-sclerosis, which has also been ascribed 
to rickets. 

On placing the ear over the anterior fontanelle, or in the temporal 
region, a systolic murmur may frequently be heard. This condition, first 
described by John D. Fisher, of Boston, in 1833, is heard with the greatest 
frequency in rickets, but its presence and persistence in perfectly healthy 
infants have been amply demonstrated.* The murmur is rarely heard after 
the fifth year. A knowledge of the existence of this systolic brain murmur 
may prevent errors. A case in which it was well marked was reported as an 
instance of supposed gummy tumor of the brain, in which the murmur 
was thought to be due to pressure on the vessels at the base. 

Changes occur in the bones of the face, chiefly in the maxilla?, which 
are reduced in size. The normal process of dentition is much disturbed; 
indeed, late teething is one of the marked features in rickets. The teeth 
which appear may be small and badly formed. 

In the upper limbs changes in the scapulae are not common. The 
clavicle may be thickened at the sternal end, and there may be thickening 
near the attachment of the sterno-cleido muscle. The most noticeable 
changes are at the lower ends of the radius and ulna. The enlargement 
is at the junction-area of the shaft and epiphysis. Less evident enlarge- 
ments may occur at the lower end of the humerus. In severe cases the 
natural shape of the bones of the arm may be much altered, since they have 
had to support the weight of the child in crawling on the floor. The 
changes in the pelvis are of special importance, particularly in female chil- 
dren, as in extreme cases they lead to great deformity and narrowing of the 
outlet. In the legs, the lower end of the tibia first becomes enlarged; and 
in slight cases it may alone be affected. In the severe forms the upper end 
of the bone, the corresponding parts of the fibula, and the lower end of 
the femur become greatly thickened. If the child walks, slight bowing of 
the tibia? inevitably results. In more advanced cases the tibiae and even 
the femora may be arched forward. In other instances the condition of 
knock-knee occurs. Unquestionably the chief cause of these deformities is 
the weight of the body in walking, but muscular action takes part in it. 
The green-stick fracture is not uncommon in the soft bones of rickets. 

These changes in the skeleton proceed slowly, and the general symp- 
toms vary a good deal with their progress. The child becomes more or 
less emaciated, though " fat rickets " is by no means uncommon, and a child 
may be well nourished but " pasty " and flabby. Fever is not constant, bat 
,in actively progressing changes in the bone there is usually a slight pyrexia. 
The abdomen is large, " pot-bellied," due partly to flatulent distention, 
partly to enlargement of the liver, and in severe cases to diminution of 
the volume of the thorax. The spleen is often enlarged and readily pal- 
pable. The urine is stated to contain an excess of lime salts, but Jacobi 
and Barlow say this has not been proved. No special or peculiar changes 
indeed, have as yet been described. There is usually slight anaemia, the 



* Osier, On the Systolic Brain Murmur of Children, Boston Medical and Surgical 
Journal, 1880. 



438 



CONSTITUTIONAL DISEASES. 



haemaglobin is absolutely and relatively decreased; a leucocytosis may or may 
not be present; it is more common with enlargement of the spleen (Morse). 
Many rickety children show marked nervous symptoms; irritability, peev- 
ishness, and sleeplessness are constantly present. Jenner called attention 
to the close relationship which existed between rickets and infantile con- 
vulsions, particularly to the fits which occur after the sixth month. Tetany 
is by no means uncommon. It involves most frequently the arms and 
hands; occasionally the legs as well. Laryngismus stridulus is a common 
complication, and though not, as some state, invariably associated with 
this disease, yet it is certainly much more frequent in rickety than in other 
children. Severe rickets interfere seriously with the growth of a child. 
Extreme examples of rickety dwarfs are not uncommon. The disease known 
as acute rickets is in reality a manifestation of scurvy and will be described 
with that disease. 

Prognosis. — The disease is never in itself fatal, but the condition of 
the child is such that it is readily carried off by intercurrent affections, 
particularly those of the respiratory organs. Spasm of the larynx and 
convulsions occasionally cause death. In females the deformity of the 
pelvis is serious, as it may lead to difficulties in parturition. 

Treatment. — The better the condition of the mother during preg- 
nancy the less likelihood is there of the development of rickets in the 
child. Rapidly repeated pregnancies and suckling a child during preg- 
nancy seem important factors in the production of the disease. Of the 
general treatment, attention to the feeding of the child is the first con- 
sideration. If the mother is unhealthy, or cannot from any cause nurse 
the child, a suitable wet-nurse should be provided, or the child must be 
artificially fed. Cows' milk, diluted according to the age of the child, 
should constitute the chief food. Care should be taken to examine the 
condition of the stools, and if curds are present the child is taking too 
much, or it is not sufficiently diluted. Barley-water or carefully strained 
and well-boiled oatmeal gruel form excellent additions to the milk. 

The child should be warmly clad and should be in the fresh air and 
sunshine the greater part of the day. It is a " vulgar error " to suppose 
that delicate children cannot stand, when carefully wrapped up, an even 
low temperature. The child should be bathed daily in warm water. Care- 
ful friction with sweet oil is very advantageous, and, if properly performed, 
allays rather than aggravates the sensitiveness. Special care should be 
taken to prevent deformity. The child should not be allowed to walk, and 
for this purpose splints applied so as to extend beyond the feet are very 
effective. Of medicines, phosphorus has been warmly recommended by 
Kassowitz, and its use is also advised by Jacobi. The child may be given 
gr. T -Lg- two or three times a day, dissolved in olive oil. The best prepara- 
tion in such cases is the elixir phosphori, six to ten or twelve minims three 
times a day (Jacobi). Cod-liver oil, in doses of from a half to one teaspoon- 
ful, is very advantageous. The syrup of the iodide of iron may be given 
with the oil. The digestive disturbances, together with the respiratory and 
nervous complications, should receive appropriate treatment. 



OBESITY. 



439 



VIII. OBESITY. 

Corpulence, an excessive development of the bodily fat — an "oily 
dropsy," in the words of Lord Byron — is a condition for which we are 
consulted in three groups of cases. First, there are persons of both sexes 
who have an hereditary tendency to obesity. Secondly, in this country 
particularly, there is an increasing number of cases of obesity in children, 
associated with bad habits in eating, and usually carelessness and lack of 
control on the part of the parents. Thirdly, and most frequently, we are 
consulted by women at the middle period of life, who are troubled with 
an over-growth of fat. While as a rule fat is no sign of health, and par- 
ticularly in children may be associated with anaemia and rickets, on the 
other hand a great many stout persons enjoy unusual vigor. Nor is obesity 
always associated with over-eating. Many stout persons are light eaters, 
and chlorotic girls with depraved or poor appetites may be very plump. 
After forty, as Sir James Paget remarks, we tend to become either thin or 
fat, and the former are usually happier and live longer. Too much food 
and too little exercise are largely responsible in about half of the cases, 
but in the hereditary ones these factors do not prevail, and this is a point 
to be borne in mind very carefully in the question of treatment. As Duck- 
worth states, gout is an important agent in many instances. 

In obesity it is now generally conceded that the carbohydrates, which 
were so long blamed, are not at fault, since they are themselves converted 
into water and carbon dioxide. On account, however, of the facility with 
which they are utilized for the purposes of oxidation, the albuminous ele- 
ments of the food are less readily oxidized and not so fully decomposed, and 
the fat is in reality separated from them. So, too, the fats themselves are 
not so prone to cause obesity as the carbohydrates, being less readily oxi- 
dized and interfering less with the complete metabolism of the albuminous 
elements. 

An extraordinary phenomenon seen occasionally in excessively fat young- 
persons is an uncontrollable tendency to sleep. 

Treatment. — We must bear in mind at the outset the injunction of 
Hippocrates (Aphorism III), speaking of a full habit of body, that extreme 
depletions are dangerous, and that the reduction must not be carried to 
an extreme. The aphorism of the celebrated George Cheyne (whose his- 
tory records one of the most successful instances of the treatment of 
obesity in literature), quoted at page 470, contains the essence of good 
sense on the subject. Put in other words, it reads — We eat too much after 
forty years of age. 

We arc often consulted by persons in whose family obesity prevails to give 
rules for the prevention of the condition in children or in women approach- 
ing the climacteric. In the case of children very much may be done by 
regulating the diet, reducing the starches and fats in the food, not allow- 
ing the children to eat sweets, and encouraging systematic exercises. In 
the case of women who tend to grow stout after child-bearing or at the 
climacteric, in addition to systematic exercises, they should be told to avoid 



440 



CONSTITUTIONAL DISEASES. 



taking too much food, and particularly to reduce the starches and sugars. 
There are a number of methods or systems in vogue at present. In the 
celebrated one of Banting, the carbohydrates and fats were excluded and 
the amount of fat was greatly reduced. Ebstein allows more fat. 

OerteFs method is given under the treatment of fatty heart. He re- 
duces the amount of liquid taken, and this is practically, too, the so-called 
Schweninger cure, in which liquids are allowed only two hours after the 
food. 

Yon Noorden's dietary, given in his exhaustive article in Nothnagel's 
Handbuch, is as follows: Eight o' clock, 80 grammes of lean, cold meat, 25 
grammes of bread, one cup of tea, with a spoonful of milk, no sugar. Ten 
o'clock, one egg. Twelve o'clock, a cup of strong meat broth. One o'clock, 
a small plate of meat soup flavored with vegetables, 159 grammes of lean 
meat of one or two sorts, partly fish, partly flesh, 100 grammes of potatoes 
with salad, 100 grammes of fresh fruit, or compote without sugar. Three 
o'clock, a cup of black coffee. Four o'clock, 200 grammes of fresh fruit. 
Six o'clock, a quarter of a litre of milk, if desired, with tea. Eight o'clock, 
125 grammes of cold meat, or 180 grammes of meat weighed raw and"' 
grilled, and eaten with pickles or radishes and salad, 30 grammes of 
Graham bread, and two or three spoonfuls of cooked fruit without sugar. 
He believes it more satisfactory to give in addition to the three meals 
smaller quantities of food at shorter intervals, so as to obviate the tendency 
to weakness which these patients often experience. In addition he allows 
twice in the day a glass of wine. The use of mineral water, weak tea, or 
lemonade is not limited at the meal times or in the intervals. 

In the treatment of extreme obesity it is very much better that the 
patient should be in hospital, or under the ca?e of a nurse, who will under- 
take the proper weighing and administration of the food. 

The thyroid extract should be used only in a systematic " cure." Five 
grains three times a day is a sufficient dose. In conjunction with the diet 
and exercises, it is useful, but it should not be ordered indiscriminately 
to fat persons. 

Adiposis Dolokosa (Dercum's Disease). 

" A disorder characterized by irregular, symmetrical deposits of fatty 
masses in various portions of the body, preceded by or attended with pain." 
It is an affection of women, occurring at the middle period of life. In 
association with neuralgic pains, fatty swellings occur in various parts of 
the body. The bunches of fat may form huge masses, pendulous, and of 
a pultaceous consistence. They do not occur on the hands, feet, or face. 
It differs from other forms of obesity in its lumpy distribution, and in 
the nervous disturbances in the form of pains and paresthesias. The 
nature of the trouble is unknown. 

In a case of Burr's, and in one of Dercum's, the thyroid gland showed 
atrophic changes. Dercum tells me that he has seen improvement from the 
use of the thyroid extract, and in one case there was a complete disappear- 
ance of all the neuritis symptoms, and a great diminution in the size of the 
fatty deposits. 



SECTION V. 



DISEASES OF THE DIGESTIVE SYSTEM. 



I. DISEASES OF THE MOUTH. 
STOMATITIS. 

(1) Acute Stomatitis. — Simple or erythematous stomatitis, the com- 
monest form of inflammation of the mouth, results from the action of 
irritants of various sorts. It is frequent at all ages. In children it is often 
associated with dentition and with gastro-intestinal disturbance, particu- 
larly in ill-nourished, unhealthy subjects. In adults it may follow the abuse 
of tobacco and the use of too hot or too highly seasoned food. It is a fre- 
quent concomitant of indigestion, and is met with in the acute specific 
fevers. 

The affection may be limited to the gums and lips or may extend over 
the whole surface of the mouth and include the tongue. There is at first 
superficial redness and dryness of the membrane, followed by increased 
secretion and swelling of the tongue, which is furred, and indented by the 
teeth. There is rarely any constitutional disturbance, but in children there 
may be slight elevation of temperature. The condition is sufficient to 
cause considerable discomfort, sometimes amounting to actual distress and 
pain, particularly in mastication. 

In infants the mouth should be carefully sponged after each feeding. 
A mouth-wash of borax or the glycerin of borax may be used, and in se- 
vere cases, which tend to become chronic, a dilute solution of nitrate of 
silver (3 or 4 grains to the ounce) may be applied. 

(2) Aphthous Stomatitis. — This form, also known as follicular or vesicu- 
lar stomatitis, is characterized by the presence of small, slightly raised 
spots, from 2 to 4 mm. in diameter, surrounded by reddened areolae. The 
spots appear first as vesicles, which rupture, leaving small ulcers with 
grayish bases and bright-red margins. They are seen most frequently on 
the inner surfaces of the lips, the edges of the tongue, and the cheeks. 
They are seldom present on the mucous membrane of the pharynx. This 
form is met with most often in children under three years. It ma} r occur 
either as an independent affection or in association with any one of the 
febrile diseases of childhood or with an attack of indigestion. The crop 

441 



442 



DISEASES OF THE DIGESTIVE SYSTEM. 



of vesicles comes out with great rapidity and the little ulcers may be fully 
formed within twenty-four hours. The child complains of soreness of the 
mouth and takes food with reluctance. The buccal secretions are increased, 
and the breath is heavy, but not foul. The constitutional symptoms are 
usually those of the disease with which the aphthae are associated. The 
disease must not be confounded with thrush. No special parasite has been 
found in connection with it. It is not a serious condition, and heals rapidly 
with the improvement of the constitutional state. In severe cases it may 
extend to the pillars of the fauces and to the pharynx, and produce ulcers 
which are irritating and difficult to heal. 

Each ulcer should be touched with nitrate of silver and the mouth 
should be thoroughly cleansed after taking food. A wash of chlorate of 
potassium, or of borax and glycerin, may be used. The constitutional symp- 
toms should receive careful attention. 

Here may be mentioned a curious affection which has been ob- 
served chiefly in southern Italy, and which is characterized by a pearly- 
colored membrane with induration, immediately beneath the tongue on 
the frsenum (Riga's disease). There may be much induration and ultimately 
ulceration. It occurs in both healthy and cachetic children, usually about 
the time of the eruption of the first teeth. It is sometimes epidemic. 

(3) Ulcerative Stomatitis. — This form, which is also known by the 
names of fetid stomatitis, or putrid sore mouth, occurs particularly in chil- 
dren after the first dentition. It may prevail as a widespread epidemic in 
institutions in which the sanitary conditions are defective. It has been 
met with in jails and camps. Insufficient and unwholesome food, improper 
ventilation, and prolonged damp, cold weather seem to be special predis- 
posing causes. Lack of cleanliness of the mouth, the presence of carious 
teeth, and the collection of tartar around them favor the development of 
the disease. The affection spreads like a specific disease, but the microbe 
has not yet been isolated. It has been held that the disease is the same 
as the foot-and-mouth disease of cattle, and that it is conveyed by the milk, 
but there is no positive evidence on these points. Payne suggests that the 
virus is identical with that of contagious impetigo. 

The morbid process begins at the margin of the gums, which become 
swollen and red, and bleed readily. Ulcers form, the bases of which are 
covered with a grayish-white, firmly adherent membrane. In severe cases 
the teeth imay become loosened and necrosis of the alveolar process may 
occur. The ulcers extend along the gum-line of the upper and lower 
jaws; the tongue, lips, and mucosa of the cheeks are usually swollen, but 
rarely ulcerated. There is salivation, the breath is foul, and mastication 
is painful. The submaxillary lymph-glands are enlarged. An exanthem 
often develops and may be mistaken for measles. The constitutional symp- 
toms are often severe, and in institutions death sometimes results in the 
case of debilitated children. 

In the treatment of this form of stomatitis chlorate of potassium has 
been found to be almost specific. It should be given in doses of 10 grains, 
three times a day, to a child, and to an adult double that amount. Locally 
it may be used as a mouth-wash, or the powdered salt may be applied di- 



STOMATITIS. 



443 



rectly to the ulcerated surfaces. When there is much fetor, a solution of 
potassium permanganate may be used as a wash, and an application of 
nitrate of silver made to the ulcers. 

There are several other varieties of ulcerative sore mouth, which differ 
entirely from this form. Ulcers of the mouth are common in nursing 
women, and are usually seen on the mucous membrane of the lips and 
cheeks. They develop from the mucous follicles, and are from 3 to 5 mm. 
in diameter. They may cause little or no inconvenience; but in some in- 
stances they are very painful and interfere seriously with the taking of 
food and its mastication. As a rule they heal readily after the application 
of nitrate of silver, and the condition is an indication for tonics, fresh air, 
and a better diet. 

Eecurring outbreaks of an herpetic, even pemphigoid, stomatitis are 
seen in neurotic individuals (stomatitis neurotica chronica, Jacobi). It may 
precede or accompany the fatal form of pemphigus vegetans. 

Parrot describes the occasional appearance in the new-born of small 
ulcers symmetrically placed on the hard palate on either side of the middle 
line. They are met with in very debilitated children. The ulcers rarely 
heal; usually they tend to increase in size, and may involve the bone. 

Bednar's aphthae consist of small patches and ulcers on the hard palate, 
caused as a rule in young infants by the artificial nipple or the nurse's 
finger. 

(4) Parasitic Stomatitis (Thrush; Soor; Muguet). — This affection, most 
commonly seen in children, is dependent upon a fungus, the saccharomyces 
albicans, called by Eobin the o'idium albicans. It belongs to the order of 
yeast fungi, and consists of branching filaments, from the ends of which 
ovoid torula cells develop. The disease does not arise apparently in a nor- 
mal mucosa. The use of an improper diet, uncleanliness of the mouth, 
the acid fermentation of remnants of food, or the development, from any 
cause, of catarrhal stomatitis predispose to the growth of the fungus. In 
institutions it is frequently transmitted by unclean feeding-bottles, spoons, 
etc. It is not confined to children, but is met with in adults in the final 
stages of fever, in chronic tuberculosis, diabetes, and in cachectic states. 
The parasite develops in the upper layers of the mucosa, and the filaments 
form a dense felt-work among the epithelial cells. The disease begins on 
the tongue and is seen in the form of slightly raised, pearly-white spots, 
which increase in size and gradually coalesce. The membrane thus formed 
can be readily scraped off, leaving an intact mucosa, or, if the process ex- 
tends deeply, a bleeding, slightly ulcerated surface. The disease spreads to 
the cheeks, lips, and hard palate, and may involve the tonsils and pharynx. 
In very severe cases the entire buccal mucosa is covered by the grayish- 
white membrane. It may even extend into the oesophagus and, according 
to Parrot, to the stomach and caecum. It is occasionally met with on the 
vocal cords. Robust, well-nourished children are sometimes affected, but 
it is usually met with in enfeebled, emaciated infants with digestive or in- 
testinal troubles. In such cases the disease may persist for months. 

The affection is readily recognized, and must not be confounded with 



DISEASES OF THE DIGESTIVE SYSTEM. 



aphthous stomatitis, in which the ulcers, preceded by the formation of 
vesicles, are perfectly distinctive. In thrush the microscopical examination 
shows the presence of the characteristic fungus throughout the membrane. 
In this condition, too, the mouth is usually dry — a striking contrast to 
the salivation accompanying aphthae. 

Thrush is more readily prevented than removed. The child's mouth 
should be kept scrupulously clean, and, if artificially fed, the bottles should 
be thoroughly sterilized. Lime-water or any other alkaline fluid, such as 
the bicarbonate of soda (a drachm to a tumbler of water), may be em- 
ployed. When the patches are present these alkaline mouth- washes may 
be continued after each feeding. A spray of borax or of sulphite of soda 
(a drachm to the ounce) or the black wash with glycerin may be employed. 
The permanganate of potassium is also useful. The constitutional treat- 
ment is of equal importance, and it will often be found that the thrush 
persists, in spite of all local measures, until the general health of the infant 
is improved by change of air or the relief of the diarrhoea, or, in obstinate 
cases, the substitution of a natural for the artificial diet. 

(5) Gangrenous Stomatitis (Cancrum Oris; Noma). — An affection 
characterized by a rapidly progressing gangrene, starting on the gums or 
cheeks, and leading to extensive sloughing and destruction. This terrible, 
but fortunately rare, disease is seen only in children under very insanitary 
conditions or during convalescence from the acute fevers. It is more 
common in girls than in boys. It is met with between the ages of two 
and five years. In at least one half of the cases the disease has developed 
during convalescence from measles. Cases have been seen also after scar- 
let fever and typhoid. The mucous membrane is first affected, usually of 
the gums or of one cheek. The process begins insidiously, and when first 
seen there is a sloughing ulcer of the mucous membrane, which spreads rap- 
idly and leads to brawny induration of the skin and adjacent parts. The 
sloughing extends, and in severe cases the cheek is perforated. The disease 
may spread to the tongue and chin; it may invade the bones of the jaws and 
even involve the eyelids and ears. In mild cases an ulcer forms on the inner 
surface of the cheek, which heals or may perforate and leave a fistulous open- 
ing. Naturally in such a severe affection the constitutional disturbance 
is very great, the pulse is rapid, the prostration extreme, and death usually 
takes place within a week or ten days. The temperature may reach 103° or 
104°. Diarrhoea is usually present, and aspiration pneumonia often de- 
velops. H. E. Wharton has described a case in which there was extensive 
colitis. Bishop and Eyan have isolated an organism which resembles in 
all points the diphtheria bacillus of reduced virulence. 

The treatment of the disease is unsatisfactory. In many cases the 
onset is so insidious that there is an extensive sloughing sore when the case 
first comes under observation. Destruction of the sore by the cautery, 
either the Paquelin or fuming nitric acid, is the most effectual. Antiseptic 
applications should be made to destroy the fetor. The child should be 
carefully nourished and stimulants given freely. 

(6) Mercurial Stomatitis (Ptyalism). — An inflammation of the mouth 
and salivary glands may be caused by mercury. It occurs chiefly in persons 



STOMATITIS. 



445 



who have a special susceptibility, and rarely now as a result of the excessive 
use of the drug. It is met with also in persons whose occupation neces- 
sitates the constant handling of mercury. It often follows the adminis- 
tration of repeated small doses. Thus, a patient with heart-disease who 
was ordered an eighth of a grain of calomel every three hours for diuretic 
purposes had, after taking eight or ten doses, a severe stomatitis, which 
persisted for several weeks. I have known it to follow the administra- 
tion of small doses of gray powder. The patient complains first of a metallic 
taste in the mouth, the gums become swollen, red, and sore, mastication 
is difficult, and soon there is a great increase in the secretion of the saliva, 
which flows freely from the mouth. The tongue is swollen, the breath has 
a foul odor, and, if the affection progresses, there may be ulceration of the 
mucosa, and, in rare instances, necrosis of the jaw. Although trouble- 
some and distressing, the disease is rarely serious, and recovery usually 
takes place in a couple of weeks. Instances in which the teeth become 
loosened or detached or in which the inflammation extends to the pharynx 
and Eustachian tubes are rarely seen now. 

The administration of mercury should be suspended so soon as the 
gums are " touched/' Mild cases of the affection subside within a few days 
and require only a simple mouth- wash. In severer cases the chlorate of po- 
tassium may be given internally, and used to rinse the mouth. The bowels 
should be freely opened; the patient should take a hot bath every evening 
and should drink plentifully of alkaline mineral waters. Atropine is some- 
times serviceable, and may be given in doses of of a grain twice a day. 
Iodine is also recommended. When the salivation is severe and protracted, 
the patient becomes much debilitated, anaemia develops, and a supporting 
treatment is indicated. The diet is necessarily liquid, for the patient finds 
the chief difficulty in taking food. If the pain is severe a Dover powder 
may be given at night. 

Here may be appropriately mentioned the influence of stomatitis, par- 
ticularly the mercurial form, upon the developing teeth of children. The 
condition known as erosion, in which the teeth are honeycombed or pitted 
owing to defective formation of enamel, is indicative, as a rule, of infantile 
stomatitis. Such teeth must be distinguished carefully from those of con- 
genital syphilis, which may of course coexist, but the two conditions are 
distinct. The honeycombing is frequently seen on the incisors; but, ac- 
cording to Jonathan Hutchinson, the test teeth of infantile stomatitis are 
the first permanent molars, then the incisors, " which are almost as con- 
stantly pitted, eroded, and of bad color, often showing the transverse fur- 
row which crosses all the teeth at the same level." Magitot regards these 
transverse furrows as the result of infantile convulsions or of severe illness 
during early life. He thinks they are analogous to the furrows on the 
nails which so often follow a serious disease. 

(7) Eczema of the Tongue (Geographical Tongue). — A remarkable 
desquamation of the superficial epithelium of the tongue in circinate 
patches, which spread while the central portions heal. Fusion of patches 
leads to areas with sinuous outlines. When extensive the tongue may be 
covered with these areas, like a geographical map. The affection causes a 



446 



DISEASES OP THE DIGESTIVE SYSTEM. 



good deal of itching and heat, and may be a source of much mental worry 
to the patients, who often dread lest it may be a commencing cancer. 

The etiology of the disease is unknown. It occurs in infants and chil- 
dren, and it is not very infrequent in adults. It has been regarded as a 
gouty manifestation, and transient attacks may accompany indigestion. 
It is very liable to relapse. In adults it may prove very obstinate, and I 
know of one instance in which the disease persisted in spite of all treat- 
ment for more than two years. Solutions of nitrate of silver give the most 
satisfactory results in relieving the intense burning. 

(8) Leukoplakia buccalis. — Samuel Plumbe described the condition as 
irthyosis lingualce. It has also been called buccal psoriasis and keratosis 
mucosal oris. There are unsymmetrical patches of various shapes, whitish 
or often pearly white in color, smooth, and without any tendency to ulcer- 
ate. They have been called lingual corns. The intensity of the opaque 
white color depends upon the thickness of the epidermis. The patches 
may extend and become slightly papillomatous. There are instances in 
which genuine epithelioma has developed from them. The condition is 
met with most commonly in heavy smokers, and is sometimes known as 
the smoker's tongue. An interesting question is the relation to syphilis. 
While somewhat similar patches develop in infected persons, the true 
syphilitic glossitis rarely presents the same opaque white, smooth appear- 
ance. It is more commonly at the edge and the point of the tongue than 
on the dorsum, and yields promptly to specific treatment. 

Leukoplakia is a very obstinate affection and resists as a rule all forms 
of treatment. All irritants, such as smoke and very hot food, should be 
avoided. Local treatment with one-half-per-cent corrosive sublimate or a 
one-per-cent chromic-acid solution has been recommended. The propriety 
of active local treatment is doubtful. The appearance of anything like 
papillomatous outgrowths should be regarded as an indication for surgical 
intervention. 



II. DISEASES OF THE SALIYAEY GLANDS. 

1. Supersecretion (Ptyalism). — The normal amount of saliva varies 
from 2 to 3 pints in the twenty-four hours. The secretion is increased 
during the taking of food and in the physiological processes of dentition. 
A great increase, to which the term ptyalism is applied, is met with under 
many circumstances. It occurs occasionally in mental and nervous affec- 
tions and in rabies. Occasionally it is seen in the acute fevers, particularly 
in small-pox. It occurs sometimes with disease of the pancreas. It has 
been met with during gestation, usually early, though it may persist 
throughout the entire course. It has been known to occur at each men- 
strual period; and, lastly, it is a common effect of certain drugs. Mercury, 
gold, copper, the iodine compounds, and (among vegetable remedies) 
jaborandi, muscarin, and tobacco excite the salivary secretion. Of these 
we most frequently see the effect of mercury in producing pt} r alism. The 
salivation may be present without any inflammation of the mouth. 



DISEASES OF THE SALIVARY GLANDS. 



2. Xerostomia (Arrest of the Salivary and Buccal Secretions; Dry 
Mouth). — In this condition, first described by Jonathan Hutchinson, the 
secretions of the mouth and salivary glands are suppressed. The tongue 
is red, sometimes cracked, and quite dry; the mucous membrane of the 
cheeks and of the palate is smooth, shining, and dry; and mastication, 
deglutition, and articulation are very difficult. The condition is not com- 
mon. A majority of the cases are in women, and in several instances have 
been associated with nervous phenomena. The general health, as a rule, 
is unimpaired. Hadden suggests that it is due to involvement of some 
centre which controls the secretion of the salivary and buccal glands. A 
well-marked case came under my observation in a man aged thirty-two, 
who was sent to me by Donald Baynes on account of a peculiar growth 
in the mouth. This proved to be the remnants of food which, owing to 
the absence of any salivary or buccal secretions, collected along the gums, 
became hardened, and adhered to them. The condition lasted for three 
weeks, and was cured by the galvanic current. 

3. Inflammation of the Salivary Glands. 
(a) Specific Parotitis. (See Mumps.) 

(6) Symptomatic parotitis or parotid oubo occurs: 

(1) In the course of the infectious fevers — typhus, typhoid, pneumonia, 
pyaemia, etc. In ordinary practice it occurs oftenest, perhaps, in typhoid 
fever. It is the result either of septic infection through the blood, or the 
inflammation, in many cases, passes up the salivary duct, and so reaches 
the gland. The process is usually very intense and leads rapidly to sup- 
puration. It is, as a rule, an unfavorable indication in the course of a fever. 
Parotitis may occur in secondary syphilis. 

(2) In connection with injury or disease of the abdomen or pelvis, a 
condition to which Stephen Paget has called special attention. Of 101 
cases of this kind, " 10 followed injury or disease of the urinary tract, 18 
were due to injury or disease of the alimentary canal, and 23 were due to 
injury or disease of the abdominal wall, the peritonaeum, or the pelvic 
cellular tissue. The remaining 50 were due to injury, disease, or tempo- 
rary derangement of the genital organs." By temporary derangement is 
meant slight injuries or natural processes — a slight blow on the testis, the 
introduction of a pessary, menstruation, or pregnancy. The etiology of 
this form of parotitis is obscure. We have had 3 cases. Many of them 
are undoubtedly septic. 

(3) In association with facial paralysis, as in a case of fatal peripheral 
neuritis described by Gowers. 

In the treatment of parotid bubo the application of half a dozen leeches 
will sometimes reduce the inflammation and promote resolution. When 
suppuration seems inevitable hot fomentations should be applied. A free 
incision should be made early. 

(c) Chronic parotitis, a condition in which the glands are enlarged, 
rarely painful, may follow inflammation of the throat or mumps. Sali- 
vation may be present. It may be due to lead, mercury, or potassium 
iodide. It occurs also in chronic Bright's disease and in secondary syphilis. 
Mikulicz has described a remarkable condition of chronic symmetrical en- 
28 



448 



DISEASES OF THE DIGESTIVE SYSTEM. 



largement of the salivary and lachrymal glands. The condition may per- 
sist for years. The case under my care mentioned in the second edition 
of this work died subsequently of tuberculosis (Am. Jr. Med. Sci., Janu- 
ary, 1898). 

(d) Gaseous Tumors of Steno's Duct and of the Parotid Gland. — In 
glass-blowers and musicians Steno's duct may become inflated with air 
and form a tumor the size of a nut or of an egg. Some have contained a 
mixture of air, saliva, and pus. In rare cases there are gaseous tumors of 
the glands, which give a sensation of crepitation on' palpation. 

III. DISEASES OF THE PHAEYKX. 

(1) Circulatory Disturbances. — (a) Hyperemia is a common condition 
in acute and chronic affections of the throat, and is frequently seen as a 
result of irritation from tobacco smoke. Venous stasis is seen in valvular 
disease of the heart, and in mechanical obstruction of the superior vena 
cava by tumor or aneurism. In aortic insufficiency the capillary pulse may 
sometimes be seen and the intense throbbing of the internal carotid may 
be mistaken for aneurism. 

(b) Haemorrhage is found in association with bleeding from other mucous 
surfaces, or it is due to local causes in the pharynx itself. In the latter 
case it may be mistaken for haemorrhage from the lungs or stomach. The 
bleeding may come from granulations or vegetations in the naso-pharynx. 
Sometimes the patient finds the pillow stained in the morning with bloody 
secretion. The condition is rarely serious, and only requires suitable local 
treatment of the pharynx. Occasionally a haemorrhage takes place into 
the mucosa, producing a pharyngeal hematoma. I have thrice seen a 
condition of the uvula resembling hemorrhagic infarction. One was in a 
patient with acute rheumatism, to whom large doses of salicylic acid had 
been given; the other two were instances of peliosis rheumatica, in both 
of which partial sloughing of the uvula took place. 

(c) (Edema. — An infiltrated (edematous condition of the uvula and 
adjacent parts is not very uncommon in conditions of debility, in profound 
anaemia, and in Bright's disease. The uvula is sometimes from this cause 
enormously enlarged, whence may arise difficulty in swallowing or in 
breathing. 

(2) Acute Pharyngitis (Sore Throat; Angina Simplex). — The entire 
pharyngeal structures, often with the tonsils, are involved. The condition 
may follow cold or exposure. In other instances it is associated with con- 
stitutional states, such as rheumatism or gout, or with digestive disorders. 
The patient complains of uneasiness and soreness in swallowing, of a feel- 
ing of tickling and dryness in the throat, together with a constant desire 
to hawk and cough. Frequently the inflammation extends into the larynx 
and produces hoarseness. Not uncommonly it is onlv part of a general 
naso-pharyngeal catarrh. The process may pass into the Eustachian tubes 
and cause slight deafness. There is stiffness of the neck, the lymph-glands 
of which may be enlarged and painful. The constitutional symptoms are 



DISEASES OF THE PHARYNX. 



449 



rarely severe. The disease sets in with a chilly feeling and slight fever; 
the pulse is increased in frequency. Occasionally the febrile symptoms 
are more severe, particularly if the tonsils are specially involved. The ex- 
amination of the throat shows general congestion of the mucous membrane, 
which is dry and glistening, and in places covered with sticky secretion. 
The uvula may be much swollen. 

Acute pharyngitis lasts only a few days and requires mild measures. 
If the tonsils are involved and the fever is high, aconite or sodium salicylate 
may be given. Guaiacum also is beneficial; but in a majority of the cases 
a calomel purge or a saline aperient and inhalations with steam meet the 
indications. 

(3) Chronic Pharyngitis. — This may follow repeated acute attacks. It 
is very common in persons who smoke or drink to excess, and in those 
who use the voice very much, such as clergymen, hucksters, and others. 
It is frequently met with in chronic nasal catarrh. The naso-pharynx and 
the posterior wall are the parts most frequently affected. The mucous 
membrane is relaxed, the venules are dilated, and roundish bodies, from 
2 to 4 mm. in diameter, reddish in color, project to a variable distance 
beyond the mucous membrane. These represent the proliferations of lymph 
tissue about the mucous glands. They may be very abundant, forming 
elongated rows in the lateral walls of the pharynx. With this there may 
be a dry glistening state of the pharyngeal mucosa, sometimes known as 
pharyngitis sicca. The pillars of the fauces and the uvula are often much 
relaxed. The secretion forms at the back of the pharynx and the patient 
may feel it drop down from the vault, or it is tenacious and adherent, and 
is only removed by repeated efforts at hawking. 

In the treatment, special attention must be paid to the general health. 
If possible, the cause should be ascertained. The condition is almost 
constant in smokers, and cannot be cured without stopping the use of 
tobacco. The use of food either too hot or too much spiced should be for- 
bidden. When it depends upon excessive exercise of the voice, rest should 
be enjoined. In many of these cases change of air and tonics help very 
much. In the local treatment of the throat gargles, washes, and pastilles 
of various sorts give temporary relief, but when the hypertrophic condi- 
tion is marked the spots should be thoroughly destroyed by the galvano- 
cautery. In many instances this affords great and permanent relief, but 
in others the condition persists, and as it is not unbearable, the patient 
gives up all hope of permanent relief. 

(4) Ulceration of the Pharynx. — (a) Follicular. The ulcers are usually 
small, superficial, and generally associated with chronic catarrh. 

(b) Syphilitic ulcers are usually painless, and most frequently situated 
on the posterior wall of the pharynx. They occur in the secondary stage 
as small, shallow excavations with the mucous patches. In the tertiary 
stage the ulcers are due to erosion of gummata, and in healing they leave 
whitish cicatrices. 

(c) Tuberculous ulceration is not very uncommon in advanced cases 
of phthisis, and, if extensive, is one of the most distressing features of the 
later stages of the disease. The ulcers are irregular, with ill-defined edges 



450 



DISEASES OF THE DIGESTIVE SYSTEM. 



and grayish-yellow bases. The posterior wall of the pharynx may have an 
eroded, worm-eaten appearance. These ulcers are, as a rule, intensely pain- 
ful. Occasionally the primary disease is about the tonsils and the pillars 
of the fauces. 

(d) Ulcers occur in connection with pseudo-membranous inflammation, 
particularly the diphtheritic. In cancer and in lupus ulcers are also present. 

(e) Ulcers are met with in certain of the fevers, particularly in typhoid. 
In many instances the diagnosis of the nature of pharyngeal ulcers is 

very difficult. The tuberculous and cancerous varieties are readily recog- 
nized, but it happens not infrequently that a doubt arises as to the syph- 
ilitic character of an ulcer. In many instances the local conditions may 
be uncertain. Then other evidences of syphilis should be sought for, 
and the patient should be placed on mercury and iodide of potassium, 
under which remedies syphilitic ulcers usually heal with great rapidity. 

(5) Acute Infectious Phlegmon of the Pharynx.— Under this term 
Senator has described cases in which, along with difficulty in swallowing, 
soreness of the throat, and sometimes hoarseness, the neck enlarges, the 
pharyngeal mucosa becomes swollen and injected, the fever is high, the 
constitutional symptoms are severe, and the inflammation passes on rap- 
idly to suppuration. The symptoms are very intense. The swelling of the 
pharyngeal tissues early reaches such a grade as to impede respiration. Very 
similar symptoms may be produced by foreign bodies in the pharynx. 

(6) Retropharyngeal abscess occurs: (1) In healthy children between 
six months and two years of age. The child becomes restless, the voice 
changes; it becomes nasal or metallic in tone, and there are pain and diffi- 
culty in swallowing. Inspection of the pharynx reveals a projecting tumor 
in the middle line, or if it be not visible, it is readily felt, on palpation, pro- 
jecting from the posterior wall. This' form has been carefully described by 
Koplik. (2) As a not infrequent sequel of the fevers, particularly of scarlet 
fever and diphtheria. (3) In caries of the bodies of the cervical vertebrae. 

The diagnosis is readily made, as the projecting tumor can be seen, or 
.felt with the finger on the posterior wall of the pharynx. 

((7) Angina Ludovici (Ludwig's Angina; Cellulitis of the NecTc). — In 
-medical practice this is seen as a secondary inflammation in the specific 
fevers, particularly diphtheria and scarlet fever. It may, however, occur 
idiopathically or result from trauma. It is probably always a streptococcus 
infection which spreads rapidly from the glands. The swelling at first is 
most marked in the submaxillary region of one side. The symptoms are, 
as a rule, intense, and, unless early and thorough surgical measures are em- 
ployed, there is great risk of systemic infection. Felix Semon holds that 
the various acute septic inflammations of the throat — acute oedema of the 
larynx, phlegmon of the pharynx and larynx, and angina Ludovici — 
" represent degrees varying in virulence of one and the same process/' 



ACUTE TONSILLITIS. 



451 



IV. DISEASES OF THE TONSILS. 
ACUTE TONSILLITIS. 

(1) Follicular or Lacunar Tonsillitis. — For practical purposes, under 
this name may be described the various forms which have been called ca- 
tarrhal, erythematous, ulcero-membranous, and herpetic. 

Etiology. — The disease is met with most frequently in young persons, 
but in children under ten it is less common than the chronic form. It is 
rare in infants. Sex has no special influence. Exposure to- wet and cold, 
and bad hygienic surroundings appear to have a direct etiological connec- 
tion with the disease. In so many instances defective drainage has been 
found associated with outbreaks of follicular tonsillitis that sewer-gas is 
regarded as a common exciting cause. One attack renders a patient more 
liable to subsequent infection. The tonsils proper and the adjacent 
lymphatic tissues undoubtedly act as portals of entry for micro-organisms, 
not only in acute rheumatism but probably in other affections. Packard 
has called particular attention to acute tonsillitis as a precursor of endo- 
carditis, erythema nodosum, and chorea. Cheadle describes it as one of 
the phases of rheumatism in childhood, with which articular attacks or 
chorea may alternate. The existence of pains in the limbs upon which 
some lay stress is no evidence of the connection of the affection with 
rheumatism. A disease so common and widespread as acute tonsillitis 
necessarily attacks many persons in whose families rheumatism prevails 
or who may themselves have had acute attacks. 

Mackenzie gives a table showing that in four successive years more 
cases occurred in September than in any other month; in October nearly 
as many, with July, August, and November next. In this country it seems 
more prevalent in the spring. So many cases develop within a short time 
that the disease may be almost epidemic. It spreads through a family in 
such a way that it must be regarded as contagious. 

An old notion prevails that there is a definite relation between the 
tonsils and the testes and ovaries. F. J. Shepherd has called attention to 
the circumstance that acute tonsillitis is a very common affection in newly 
married persons. That view is probably correct which regards tonsillitis 
as a local disease with severe constitutional manifestations, although the 
fever is often out of proportion to the local symptoms. The commonest 
organism found in tonsillitis is a streptococcus. Staphylococci also occur. 
In some cases the bacillus diphtheria of Loeffler has been found, but it 
does not always possess the full virulence (see Atypical Forms of Diph- 
theria). 

Morbid Anatomy.— The lacuna? of the tonsils become filled with 
exudation products, which form cheesy-looking masses, projecting from 
the orifices of the crypts. Not infrequently the exudations from contiguous 
lacunae coalesce. The intervening mucosa is usually swollen, deep-red in 
color, and may present herpetic vesicles or, in some instances, even mem- 
branous exudation, in which case it may be difficult to distinguish the con- 



452 



DISEASES OF THE DIGESTIVE SYSTEM. 



dition from diphtheria. The creamy contents of the crypt are made up of 
micrococci and epithelial debris. 

Symptoms. — Chilly feelings, or even a definite chill, and aching pains 
in the back and limbs may precede the onset. The fever rises rapidly, and 
in the case of a young child may reach 105° on the evening of the first day. 
The patient complains of soreness of the throat and difficulty in swallow- 
ing. On examination, the tonsils are seen to be swollen and the crypts 
present the characteristic creamy exudate. The tongue is furred, the 
breath is heavy and foul, and the urine is highly colored and loaded with 
urates. In children the respirations are usually very hurried, and the 
pulse is greatly increased in rapidity. Swallowing is painful, and the voice 
often becomes nasal. Slight swelling of the cervical glands is present. In 
severe cases the symptoms increase and the tonsils become still more swollen. 
The inflammation gradually subsides, and, as a rule, within a week the 
fever departs and the local condition greatly improves. The tonsils, how- 
ever, remain somewhat swollen. The prostration and constitutional dis- 
turbance are often out of proportion to the intensity of the local disease. 

There are complications which occasionally excite uneasiness. Febrile 
albuminuria is not uncommon, as Haig-Brown has pointed out. Cases of 
endocarditis or pericarditis have been found. It is to be borne in mind 
that in children an apex systolic murmur is by no means uncommon at 
the height of any fever. The disease may extend to the middle ear. The 
development of paralytic symptoms, local or general, after an attack which 
has been regarded as follicular tonsillitis indicates an error in diagnosis. 
A diffuse erythema may develop, simulating that of scarlet fever. 

Diagnosis. — It may be difficult to distinguish follicular tonsillitis 
from diphtheria. It would seem, indeed, as if there were intermediate 
forms between the mildest lacunar and the severer pseudo-membranous 
tonsillitis. In the follicular form the individual yellowish-gray masses, 
separated by the reddish tonsillar tissue, are very characteristic; whereas 
in diphtheria the membrane is of ashy gray, and uniform, not patchy. A 
point of the greatest importance in diphtheria is that the membrane is not 
limited to the tonsils, but creeps up the pillars of the fauces or appears on 
the uvula. The diphtheritic membrane when removed leaves a bleeding, 
eroded surface; whereas the exudation of lacunar tonsillitis is easily sepa- 
rated, and there is no erosion beneath it. In all doubtful cases cultures 
should be made to determine the presence or absence of Loeffler's bacillus. 

(2) Suppurative Tonsillitis. t 

Etiology. — This arises under conditions very similar to those men- 
tioned in the lacunar form. It may follow exposure to cold or wet, and is 
particularly liable to recur. It is most common in adolescence. The in- 
flammation is here more deeply seated. It involves the stroma, and tends 
to go on to suppuration. 

Symptoms. — The constitutional disturbance is very great. The tem- 
perature rises to 104° or 105°, and the pulse ranges from 110 to 130. Noc- 
turnal delirium is not uncommon. The prostration may be extreme. There 
is no local disease of similar extent which so rapidly exhausts the strength 
of a patient. Soreness and dryness of the throat, with pain in swallowing, 



ACUTE TONSILLITIS. 



453 



are the symptoms of which the patient first complains. One or both tonsils 
may be involved. They are enlarged, firm to the touch, dusky red and 
cedematous, and the contiguous parts are also much swollen. The swelling 
of the glands may be so great that they meet in the middle line, or one 
tonsil may even push the uvula aside and almost touch the other gland. 
The salivary and buccal secretions are increased. The glands of the neck 
enlarge, the lower jaw is fixed, and the patient is unable to open his mouth. 
In from two to four days the enlarged gland becomes softer, and fluctuation 
can be distinctly felt by placing one finger on the tonsil and the other at 
the angle of the jaw. The abscess points usually toward the mouth, but in 
some cases toward the pharynx. It may burst spontaneously, affording 
instant and great relief. Suffocation has followed the rupture of a large 
abscess and the entrance of the pus into the larynx. When the suppura- 
tion is peritonsillar and. extensive, the internal carotid artery may be 
opened; but these are, fortunately, very rare accidents. 

Treatment. — In the follicular form aconite may be given in full doses. 
It acts very beneficially in children. The salicylates, given freely at the 
outset, are regarded by some as specific, but I have seen no evidence of 
such prompt and decisive action. At night, a full dose of Dover's powder 
may be given. The use of guaiacum, in the form of 2-grain lozenges, is 
warmly recommended. Iron and quinine should be reserved until the fever 
has subsided. A pad of spongio-piline or thick flannel dipped in ice-cold 
water may be applied around the neck and covered with oiled silk. More 
convenient still is a small ice-bag. Locally the tonsils may be treated with 
the dry sodium bicarbonate. The moistened fingertip is dipped into the 
soda, which is then rubbed gently on the gland and repeated every hour. 
Astringent preparations, such as iron and glycerin, alum, zinc, and nitrate 
of silver, may be tried. To cleanse and disinfect the throat, solutions of 
borax or thymol in glycerin and water may be used. 

In suppurative tonsillitis hot applications in the form of poultices and 
fomentations are more comfortable and better than the ice-bag. The 
gland should be felt — it cannot always be seen — from time to time, and 
should be opened when fluctuation is distinct. The progress of the dis- 
ease may be shortened and the patient spared several days of great suffer- 
ing if the gland is scarified early. The curved bistoury, guarded nearly 
to the point with plaster or cotton, is the most satisfactory instrument. 
The incision should be made from above downward, parallel with the an- 
terior pillar. There are cases in which, before suppuration takes place, the 
parenchymatous swelling is so great that the patient is threatened with 
suffocation. In such instances the tonsil must either be excised or trache- 
otomy or, possibly, intubation performed. Delavan refers to two cases in 
which he states that tracheotomy would, under these circumstances, have 
saved life. Patients with this affection require a nourishing liquid diet, 
and during convalescence iron in full doses. 

Early removal of the tonsils should be practiced when a child suffers 
with recurring attacks, and thorough local treatment should be given to 
the naso-pharynx. Particular care should be taken of the child's mouth 
and throat. 



454 



DISEASES OP THE DIGESTIVE SYSTEM. 



CHRONIC TONSILLITIS. 

(Chronic Naso-pharyngeal Obstruction ; Mouth- Breathing ; Aprosexia.) 

Under this heading will be considered also hypertrophy of the adenoid 
tissue in the vault of the pharynx, sometimes known as the pharyngeal 
tonsil, as the affection usually involves both the tonsils proper and this 
tissue, and the symptoms are not to be differentiated. 

Chronic enlargement of the tonsillar tissues is an affection of great im- 
portance, and may influence in an extraordinary way the mental and bodily 
development of children. 

Etiology. — Hypertrophy of the tonsillar structures is occasionally con- 
genital. Cases are perhaps most frequent in children, during the third 
hemi-decade. The condition also occurs in young adults, more rarely in 
the middle-aged. The enlargement may follow diphtheria or the eruptive 
fevers. The frequency of the occurrence of adenoid growths in the naso- 
pharynx has been variously stated. Meyer, to whom the profession is in- 
debted for calling attention to the subject, found them in about one per 
cent of the children in Copenhagen, while Chappell found 60 cases in the 
examination of 2,000 children in New York. These figures give a very 
moderate estimate of the prevalence of the trouble. It occurs equally in 
boys and girls, according to some writers with greater prevalence in the 
former. 

Morbid Anatomy. — The tonsils proper present a condition of 
chronic hypertrophy, due to multiplication of all the constituents of the 
glands. The lymphoid elements may be chiefly involved without much 
development of the stroma. In other instances the fibrous matrix is in- 
creased, and the organ is then harder, smaller, firmer, and is cut with much 
greater difficulty. 

The adenoid growths, which spring from the vault of the pharynx, 
form masses varying in size from a small pea to an almond. They may 
be sessile, with broad bases, or pedunculated. They are reddish in color, 
of moderate firmness, and contain numerous blood-vessels. " Abundant, 
as a rule, over the vault, on a line with the fossa of the Eustachian tube, 
the growths may lie posterior to the fossa — namely, in the depression known 
as the fossa of Kosenmuller, or upon the parts which are parallel to the 
posterior wall of the pharynx. The growths appear to spring in the main 
from the mucous membrane covering the localities where the connective 
tissue fills in the inequalities of the base of the skull " (Harrison Allen). 
The growths are most frequently papillomatous with a lymphoid par- 
enchyma. Hypertrophy of the pharyngeal adenoid tissue may be present 
without great enlargement of the tonsils proper. Chronic catarrh of the 
nose usually coexists. 

Symptoms. — The direct effect of chronic tonsillar hypertrophy is 
the establishment of mouth-breathing. The indirect effects are deforma- 
tion of the thorax, changes in the facial expression, sometimes marked 
alteration in the mental condition, and in certain cases stunting of the 
growth. Woods Hutchinson has suggested that the embryological relation 



CHRONIC TONSILLITIS. 



455 



of these structures with the pituitary body may account for the interfer- 
ence with development. The establishment of mouth-breathing is the 
symptom which first attracts the attention. It is not so noticeable by day, 
although the child may present the vacant expression characteristic of this 
condition. At night the child's sleep is greatly disturbed; the respirations 
are loud and snorting, and there are sometimes prolonged pauses, followed 
by deep, noisy inspirations. The pulse may vary strangely during these 
attacks, and in the prolonged intervals may be slow, to increase greatly 
with the forced inspirations. The alas nasi should be observed during 
the sleep of the child as they are sometimes much retracted during in- 
spiration, due to a laxity of the walls, a condition readily remedied by the 
use of* a soft wire dilator. Night terrors are common. The child may wake 
up in a paroxysm of shortness of breath. Sometimes there is a nocturnal 
paroxysmal cough of a very troublesome character (Balne's cough), usually 
excited by lying down. The attacks may occur through the day. 

When the mouth-breathing has persisted for a long time definite changes 
are brought about in the face, mouth, and chest. The facies is so peculiar 
and distinctive that the condition may be evident at a glance. The ex- 
pression is dull, heavy, and apathetic, due in part to the fact that the mouth 
is habitually left open. In long-standing cases the child is very stupid- 
looking, responds slowly to questions, and may be sullen and cross. The 
lips are thick, the nasal orifices small and pinched-in looking, the supe- 
rior dental arch is narrowed and the roof of the mouth considerably raised. 

The remarkable alterations in the shape of the chest in connection 
with enlarged tonsils were first carefully studied by Dupuytren (1828), 
who evidently fully appreciated the great importance of the condition. 
He noted " a lateral depression of the parietes of the chest consisting of a 
depression, more or less great, of the ribs on each side, and a proportionate 
protrusion of the sternum in front/' J. Mason Warren (Medical Exam- 
iner, 1839) gave an admirable description of the constitutional symptoms 
and the thoracic deformities induced by enlarged tonsils. These, with 
the memoir of Lambron (1861), constitute the most important contribu- 
tions to our knowledge on the subject. Three types of deformity may be 
recognized: 

(a) The Pigeon or Chicken Breast, by far the most common form, in 
which the sternum is prominent and there is a circular depression in the 
lateral zone (Harrison's gro&ve), corresponding to the attachment of the 
diaphragm. The ribs are prominent anteriorly and the sternum is angu- 
lated forward at the manubrio-gladiolar junction. As a mouth-breather 
is watched during sleep, one can see the lower and lateral thoracic regions 
retracted during inspiration by the action of the diaphragm. 

(b) Barrel Chest. — Some children, the subject of chronic naso-pharyn- 
geal obstruction, have recurring attacks of asthma, and the chest may be 
gradually deformed, becoming rounded and barrel-shaped, the neck short, 
and the shoulders and back bowed. A child of ten or eleven may have the 
thoracic conformation of an old man with emphysema. 

(c) The Funnel Breast (Trichterbrust). — This remarkable deformity, 
in which there is a deep depression at the lower sternum, has excited much 



456 



DISEASES OF THE DIGESTIVE SYSTEM. 



controversy as to its mode of origin. I believe that in some instances, at 
least, it is due to the obstructed breathing in connection with adenoid 
vegetations. I have seen two cases in children, in which the condition was 
in process of development. During inspiration the lower sternum was 
forcibly retracted, so much so that at the height the depression corre- 
sponded to that of a well-marked " Trichterbrust." While in repose, the 
lower sternal region was distinctly excavated. 

The voice is altered and acquires a nasal quality. The pronunciation 
of certain letters is changed, and there is inability to pronounce the nasal 
consonants n and m. Bloch lays great stress upon the association of mouth- 
breathing with stuttering. 

The hearing is impaired, usually owing to the extension of inflamma- 
tion along the Eustachian tubes and the obstruction with mucus or the 
narrowing of their orifices by pressure of the adenoid vegetations. In some 
instances it may be due to retraction of the drums, as the upper pharynx 
is insufficiently supplied with air. Naturally the senses of taste and smell 
are much impaired. With these symptoms there may be little or no nasal 
catarrh or discharge, but the pharyngeal secretion of mucus is always in- 
creased. Children, however, do not notice this, as the mucus is usually 
swallowed, but older persons expectorate it with difficulty. 

Among other symptoms may be mentioned headache, which is by no 
means uncommon, general listlessness, and an indisposition for physical 
or mental exertion. Habit-spasm of the face has been described in con- 
nection with it. I have known several instances in which permanent relief 
has been afforded by the removal of the adenoid vegetations. Enuresis 
is occasionally an associated symptom. The influence upon the mental 
development is striking. Mouth-breathers are usually dull, stupid, and 
backward. It is impossible for them to fix the attention for long at a time, 
and to this impairment of the mental function Guye, of Amsterdam, has 
given the name aprosexia. Headaches, forgetfulness, inability to study 
without discomfort, are frequent symptoms of this condition in students. 
There is more than a grain of truth in the aphorism shut your mouth and 
save your life, which is found on the title-page of Captain Catlings cele- 
brated pamphlet on mouth-breathing. 

A symptom specially associated with enlarged tonsils is fetor of the 
breath. In the tonsillar crypts the inspissated secretion undergoes • de- 
composition and an odor not unlike that of Roquefort or Limburger cheese 
is produced. The little cheesy masses may sometimes be squeezed from 
the crypts of the tonsils. Though the odor may not apparently be very 
strong, yet if the mass be squeezed between the fingers its intensity will at 
once be appreciated. In some cases of chronic enlargement the cheesy 
masses may be deep in the tonsillar crypts; and if they remain for a pro- 
longed period lime salts are deposited and a tonsillar calculus is in this 
way produced. 

Children with enlarged tonsils are especially prone to take cold and to 
recurring attacks of follicular disease. They are also more liable to diph- 
theria, and in them the anginal features in scarlet fever are always more 
serious. The ultimate results of untreated adenoid hypertrophy are im- 



CHRONIC TONSILLITIS. 



457 



portant. In some cases the vegetations disappear, leaving an atrophic 
condition of the vault of the pharynx. Neglect may also lead to the so- 
called Thornwaldt's disease, in which there is a cystic condition of the 
pharyngeal tonsil and constant secretion of muco-pus. 

Diagnosis. — The facial aspect is usually distinctive. Enlarged ton- 
sils are readily seen on inspection of the pharynx. There may be no great 
enlargement of the tonsils and nothing apparent at the back of the throat 
even when the naso-pharynx is completely blocked with adenoid vegeta- 
tions. In children the rhinoscopic examination is rarely practicable. Digi- 
tal examination is the most satisfactory. The growths can then be felt 
either as small, flat bodies or, if extensive, as velvety, grape-like papillo- 
mata. ' 

Treatment. — If the tonsils are large and the general state is evidently 
influenced by them they should be at once removed. Applications of 
iodine and iron, or pencilling the crypts with nitrate of silver, are of service 
in the milder grades, but it is waste of time to apply them in very enlarged 
glands. There is a condition in which the tonsils are not much enlarged, 
but the crypts are constantly filled with cheesy secretions and cause a 
very bad odor in the breath. In such instances the removal of the secre- 
tion and thorough pencilling of the crypts with chromic acid may be prac- 
tised. The galvano-cautery is of great service in many cases of enlarged 
tonsils when there is any objection to the more radical surgical procedure. 

The treatment of the adenoid growths in the pharynx is of the great- 
est importance, and should be thoroughly carried out. Parents should 
be frankly told that the affection is serious, one which impairs the mental 
not less than the bodily development of the child. In spite of the thorough 
ventilation of this subject by specialists, practitioners do not appear to 
have grasped as yet the full importance of this disease. They are far too 
apt to temporize and unnecessarily to postpone radical measures. The 
child must be etherized, when the growths can be removed either with the 
finger-nail, which in most instances is sufficient, or with a suitable curette. 
The dangers of the operation are slight. Haemorrhage occurs and may 
be severe. Death from chloroform has been somewhat frequent. Hinckel 
(N. Y. Med. Jr., Oct. 29, 1898) has collected 18 cases. The good effects 
of the operation are often apparent within a few days, and the child begins 
to breathe through the nose. In some instances the habit of mouth-breath- 
ing persists. As soon as the child goes to sleep the lower jaw drops and 
the air is drawn into the mouth. In these cases a chin strap can be readily 
adjusted, which the child may wear at night. In severe cases it may take 
months of careful training before the child can speak properly. 

Throughout the entire treatment attention should be paid to hygiene 
and diet, and cod-liver oil and the iodide of iron may be administered with 
benefit. 



458 



DISEASES OF THE DIGESTIVE SYSTEM. 



Y. DISEASES OF THE (ESOPHAGUS. 
I. ACUTE OESOPHAGITIS. 

Etiology. — Acute inflammation occurs (a) in the catarrhal processes 
of the specific fevers; more rarely as an extension from catarrh of the 
pharynx, (b) As a result of intense mechanical or chemical irritation, 
produced by foreign bodies, by very hot liquids, or by strong corrosives. 
(c) In the form of pseudo-membranous inflammation in diphtheria, and 
occasionally in pneumonia, typhoid fever, and pyaemia, (d) As a pustular 
inflammation in small-pox, and, according to Laennec, as a result of a pro- 
longed administration of tartar emetic, (e) In connection with local dis- 
ease, particularly cancer either of the tube itself or extension to it from 
without. And, lastly, acute oesophagitis, occasionally with ulceration, may 
occur spontaneously in sucklings. 

Morbid Anatomy. — It is extremely rare to see redness of the 
mucosa, except when chemical irritants have been swallowed. More com- 
monly the epithelium is thickened and has desquamated, so that the sur- 
face is covered with a fine granular substance. The mucous follicles are 
swollen and occasionally there may be seen small erosions. In the pseudo- 
membranous inflammation there is a grayish croupous exudate, usually lim- 
ited in extent, at the upper portion of the gullet. This must not be con- 
founded with the grayish-white deposit of thrush in children. The pus- 
tular disease is very rare in small-pox. In the phlegmonous inflammation 
the mucous membrane is greatly swollen, and there is purulent infiltration 
in the submucosa. This may be limited as about a foreign body, or ex- 
tremely diffuse. It may even extend throughout a large part of the gullet. 
Gangrene occasionally supervenes. There is a remarkable fibrinous or 
membranous oesophagitis, which is most frequently met with in the fevers, 
sometimes also in hysteria, in which long casts of the tube may be vomited. 

Symptoms. — Pain in deglutition is always present in severe inflam- 
mation of the oesophagus, and in the form which follows the swallowing 
of strong irritants may prevent the taking of food. A dull pain beneath 
the sternum is also present. In the milder forms of catarrhal inflamma- 
tion there are usually no symptoms. The presence of a foreign body is 
indicated by dysphagia and spasm with the regurgitation of portions of 
the food. Later, blood and pus may be ejected. It is surprising how ex- 
tensive the disease may be in the oesophagus without producing much pain 
or great discomfort, except in swallowing. The intense inflammation 
which follows the swallowing of corrosives, when not fatal, gradually sub- 
sides, and often leads to cicatricial contraction and stricture. 

The treatment of acute inflammation of the oesophagus is extremely un- 
satisfactory, particularly in the severer forms. The slight catarrhal cases 
require no special treatment. When the dysphagia is intense it is best not 
to give food by the mouth, but to feed entirely by enemata. Fragments of 
ice may be given, and as the pain and distress subside, demulcent drinks. 
External applications of cold often give relief. 



SPASM OF THE (ESOPHAGUS. 



459 



A chronic form of oesophagitis is described, but this results usually from 
the prolonged action of the causes which produce the acute form. 

Ulceration of the (Esophagus. — In many cachectic conditions catarrhal 
ulceration is found. In a few rare instances ulcers of the oesophagus are 
met with in typhoid fever. Acute malignant ulceration may perforate the 
oesophagus and open into the aorta. 

Associated with chronic heart-disease and more frequently with the 
senile and the cirrhotic liver, the oesophageal veins may be enormously 
distended and varicose, particularly toward the stomach. In these cases 
the mucous membrane is in a state of chronic catarrh, and the patient has 
frequent eructations of mucus. Rupture of these oesophageal veins may 
cause fatal haemorrhage. Two cases of the kind have occurred in my ex- 
perience. The blood may pass per rectum alone, as in a case reported by 
Power, of Baltimore, in 1839. 



II. SPASM OF THE CESOPHAGUS ((Esophagismus). 

This so-called spasmodic stricture of the gullet is met with in hysterical 
patients and hypochondriacs, also in chorea, epilepsy, and especially hydro- 
phobia. It is sometimes associated also with the lodgment of foreign bodies. 
The idiopathic form is found in females of a marked neurotic habit, but 
may also occur in elderly men. It may be present only during pregnancy. 
Of 4 cases which have come under my observation, 2 were in men, one a 
hypochondriac over sixty years of age who for many months had taken 
only liquid food, and with great difficulty, owing to a spasm which accom- 
panied every attempt to swallow. The readiness with which the bougie 
passed and the subsequent history showed the true nature of the case. The 
patient complains of inability to swallow solid food, and in extreme in- 
stances even liquids are rejected. The attack may come on abruptly, and 
be associated with emotional disturbances and with substernal pain. The 
bougie, when passed, may be arrested temporarily at the seat of the spasm, 
which gradually yields, or it may slip through without the slightest effort. 
The condition is rarely serious. Death has, however, followed it. 

The diagnosis is not difficult, particularly in young persons with marked 
nervous manifestations. In elderly persons oesophagismus is almost always 
connected with hypochondriasis, but great care must be taken to exclude 
cancer. 

In some cases a cure is at once effected by the passage of a bougie. The 
general neurotic condition also requires special attention. 

Paralysis of the oesophagus scarcely demands separate consideration. 
It is a very rare condition, due most often to central disease, particularly 
bulbar paralysis. It may be peripheral in origin, as in diphtheritic paraly- 
sis. Occasionally it occurs also in hysteria. The essential symptom is 
dysphagia. 



460 



DISEASES OF THE DIGESTIVE SYSTEM. 



III. STRICTURE OF THE (ESOPHAGUS. 

This results from: (a) Congenital narrowing, (h) The cicatricial con- 
traction of healed ulcers, usually due to corrosive poisons, occasionally 
to syphilis, and in rare instances after the fevers, (c) The growth of 
tumors in the walls, as in the so-called cancerous stricture. Eighty-five 
per cent of the cases are of this nature (Kelynack and Anderson), (d) 
External pressure by aneurism, enlarged lymph-glands, enlarged thyroid, 
other tumors, and sometimes by pericardial effusion. . 

The cicatricial stricture may occur anywhere in the gullet, and in ex- 
treme cases may, indeed, involve the whole tube, but in a majority of in- 
stances it is found either high up near the pharynx or low down toward 
the stomach. The narrowing may be extreme, so that only small quanti- 
ties of food can trickle through, or the obstruction may be quite slight. 
There is usually no difficulty in making a diagnosis of the cicatricial strict- 
ure, as the history of mechanical injury or the swallowing of a corrosive 
fluid makes clear the nature of the case. When the stricture is low down 
the oesophagus is dilated and the walls are usually much hypertrophied. 
When the obstruction is high in the gullet, the food is usually rejected at 
once, whereas, if it is low, it may be retained and a considerable quantity 
collects before it is regurgitated. Any doubt as to its having reached the 
stomach is removed by the alkalinity of the material ejected and the absence 
of the characteristic gastric odor. Auscultation of the oesophagus may be 
practised and is sometimes of service. The patient takes a mouthful of 
water and the auscultator listens along the left of the spine. The normal 
oesophageal bruit may be heard later than seven seconds, the normal time, or 
there may be heard a loud splashing, gurgling sound. The secondary mur- 
mur, heard as the fluid enters the stomach, may be absent. The passage of 
the oesophageal bougie will determine more accurately the locality. Conical 
bougies attached to a flexible whalebone stem are the most satisfactory, but 
the gum-elastic stomach tube may be used; a large one should be tried first. 
The patient should be placed on a low chair with the head well thrown 
back. The index finger of the left hand is passed far into the pharynx, 
and in some instances this procedure alone may determine the presence of 
a new growth. The bougie is passed beside the finger until it touches the 
posterior wall of the pharynx, then along it, more to one side than in the 
middle line, and so gradually pushed into the gullet. It is to be borne 
in mind that in passing the cricoid cartilage there is often a slight ob- 
struction. Great gentleness should be used, as it has happened more than 
once that the bougie has been passed through a cancerous ulcer into the 
mediastinum or through a diverticulum. I have known this accident to 
happen twice — once in the case of a distinguished surgeon, who performed 
cesophagotomy and passed the tube, as he thought, into the stomach. The 
post mortem on the next day showed that the tube had entered a diverticu- 
lum and through it the left pleura, in which the milk injected through 
the tube was found. In the other instance the tube passed through a can- 
cerous ulcer into the lung, which was adherent and inflamed. Fortunately 



CANCER OF THE (ESOPHAGUS. 



461 



these accidents, sometimes unavoidable, are extremely rare. It is well 
always, as a precautionary measure before passing the bougie, to examine 
carefully for aneurism, which may produce all the symptoms of organic 
stricture. In cases in which the narrowing is extreme there is always ema- 
ciation. For treatment, surgical works must be consulted. 



IV. CANCER OF THE CESOPHAGUS. 

This is usually epithelioma. It is not an uncommon disease, and occurs 
more frequently in males than in females. The middle and lower thirds are 
most often affected. At first confined to the mucous membrane, the can- 
cer gradually increases and soon ulcerates. The lumen of the tube is nar- 
rowed, but when ulceration is extensive in the later stages the stricture 
may be less marked. Dilatation of the tube and hypertrophy of the walls 
usually take place above the cancer. The ulcer may perforate the trachea 
or a bronchus, the lung, the pleura, the mediastinum, the aorta or one of 
its larger branches, the pericardium, or it may erode the vertebral column. 
The recurrent laryngeal nerves are not infrequently implicated. Perfora- 
tion of the lung produces, as a rule, local gangrene. 

Symptoms. — The earliest symptom is dysphagia, which is progressive 
and may become extreme, so that the patient emaciates rapidly. Kegurgita- 
tion may take place at once; or, if the cancer is situated near the stomach, 
it may be deferred for ten or fifteen minutes, or even longer if the tube 
is much dilated. The rejected materials may be mixed with blood and may 
contain cancerous fragments. In persons over fifty years of age persistent 
difficulty in swallowing accompanied by rapid emaciation usually indicates 
oesophageal cancer. The cervical lymph-glands are frequently enlarged and 
may give early indication of the nature of the trouble. Pain may be per- 
sistent or be present only when food is taken. In certain instances the pain 
is very great. I saw an autopsy on a case of cancer of the oesophagus in 
which the patient gradually became emaciated, but had no special symp- 
toms to call attention to the disease. These latent cases are, however, very 
rare. Bronchitis and broncho-pneumonia are common terminal events. 

The prognosis is hopeless; the patients usually become progressively 
emaciated, and die either of asthenia or sudden perforation of the ulcer. 

In the diagnosis of the condition it is important, in the first place, to 
exclude pressure from without, as by aneurism or other tumor. The his- 
tory enables us to exclude cicatricial stricture and foreign bodies. The 
sound may be passed and the presence of the stricture determined. As 
mentioned above, great care should be exercised. Fragments of carcinom- 
atous tissue may in some instances be removed with the tube. On aus- 
cultation along the left side of the spine the primary oesophageal murmur 
may be much altered in quality. 

Treatment. — In most cases milk and liquids can be swallowed, but sup- 
plementary nourishment should be given by the rectum. It may be ad- 
visable in some instances to pass a tube into the stomach and introduce 
food in this way. When there is difficulty in feeding the patient it is very 



462 



DISEASES OF THE DIGESTIVE SYSTEM. 



much better to have gastrotomy performed at once, as it gives the greatest 
comfort and ease, and prolongs the patients life. 

V. RUPTURE OF THE CESOPHAGUS. 

(1) In a healthy organ as a result of prolonged vomiting after a full 
meal, or when intoxicated. Eight cases are on record (Virchow's Archiv, 
vol. 162). Boerhaave described the first case in Baron Wassennar, who 
" broke asunder the tube of the oesophagus near the diaphragm, so that, 
after the most excruciating pain, the elements which he swallowed passed, 
together with the air, into the cavity of the thorax, and he expired in 
twenty-four hours/' 

(2) In a few cases the rupture has occurred in a diseased and weakened 
tube, near the scar of an ulcer, for example. 

(3) Post-mortem softening — oesophago-malacia — a not very uncommon 
condition, must not be mistaken for it. In spontaneous rupture the rent 
is clean-cut and circumferential; in malacia it is rounded and often cribri- 
form, and the margins are softened. The contents of the stomach may be 
in the left pleura. 

VI. DILATATIONS AND DIVERTICULA. 

Stenosis of the gullet is followed by secondary dilatation of the tube 
above the constriction and great hypertrophy of the walls. Primary dila- 
tation is extremely rare. The tube may attain extraordinary dimensions — 
30 cm. in circumference in Luschka's case. Eegurgitation of food is the 
most common symptom. There may also be difficulty in breathing from 
pressure. 

Diverticula are of two forms: (a) Pressure diverticula, which are most 
common at the junction of the pharynx and gullet, on the posterior wall. 
Owing to weakness of the muscles at this spot, local bulging occurs, which 
is gradually increased by the pressure of food, and finally forms a saccular 
pouch, (b) The traction diverticula situated on the anterior wall near the 
bifurcation of the trachea, result, as a rule, from the extension of inflam- 
mation from the lymph-glands with adhesion and subsequent cicatricial 
contraction, by which the wall of the gullet is drawn out. Diverticula have 
been successfully extirpated by von Bergmann and by Mixter. 

A rare and remarkable condition, of which a case has been recorded 
by MacLachlan, and of which a second is in attendance at my clinic, is the 
cesophago-pleuro-cutaneous fistula. In my patient fluids are discharged 
at intervals through a fistula in the right infra-clavicular region, which 
appears to communicate with a cavity in the upper part of the pleura or 
lung. The condition has persisted for more than twenty years. 



ACUTE GASTRITIS. 



463 



VI. DISEASES OF THE STOMACH. 
I. ACUTE GASTRITIS. 

(Simple Gastritis; Acute Gastric Catarrh; Acute Dyspepsia.) 

Etiology. — Acute gastric catarrh, one of the most common of com- 
plaints, occurs at all ages, and is usually traceable to errors in diet. It may 
follow the ingestion of more food than the stomach can digest, or it may 
result from taking unsuitable articles, which either themselves irritate the 
mucosa or, remaining undigested, decompose, and so excite an acute dys- 
pepsia. A frequent cause is the taking of food which has begun to decom- 
pose, particularly in hot weather. In children these fermentative processes 
are very apt to excite acute catarrh of the bowels as well. Another very 
common cause is the abuse of alcohol, and the acute gastritis which fol- 
lows a drinking-bout is one of the most typical forms of the disease. The 
tendency to acute indigestion varies very much in different individuals, 
and indeed in families. We recognize this in using the expressions a " deli- 
cate stomach " and a " strong stomach." Gouty persons are generally 
thought to be more disposed to acute dyspepsia than others. Acute catarrh 
of the stomach occurs at the outset of many of the infectious fevers. 

Lebert described a special infectious form of gastric catarrh, occurring 
in epidemic form, and only to be distinguished from mild typhoid fever by 
the absence of rose spots and swelling of the spleen. Many practitioners 
still adhere to the belief that there is a form of gastric fever, but the evidence 
of its existence is by no means satisfactory, and certainly a great majority 
of all cases in this country are examples of mild typhoid. 

Morbid Anatomy. — Beaumont's study of St. Martin's stomach 
showed that in acute catarrh the mucous membrane is reddened and swol- 
len, less gastric juice is secreted, and mucus covers the surface. Slight 
haemorrhages may occur or even small erosions. The submucosa may be 
somewhat cedematous. Microscopically the changes are chiefly noticeable 
in the mucous and peptic cells, which are swollen and more granular, and 
there is an infiltration of the intertubular tissue with leucocytes. 

Symptoms. — 7n mild cases the symptoms are those of slight "indi- 
gestion " — an uncomfortable feeling in the abdomen, headache, depression, 
nausea, eructations, and vomiting, which usually gives relief. The tongue 
is heavily coated and the saliva is increased. In children there are intes- 
tinal symptoms — diarrhoea and colicky pains. There is usually no fever. 
The duration is rarely more than twenty-four hours. In the severer forms 
the attack may set in with a chill and febrile reaction, in which the tem- 
perature rises to 102° or 103°. The tongue is furred, the breath heavy, and 
vomiting is frequent. The ejected substances, at first mixed with food, 
subsequently contain much mucus and bile-stained fluids. There may be 
constipation, but very often there is diarrhoea. The urine presents the 
usual febrile characteristics, and there is a heavy deposit of urates. The 
abdomen may be somewhat distended and slightly tender in the epigastric 
region. Herpes may appear on the lips. The attack may last from one 
29 



464 



DISEASES OF THE DIGESTIVE SYSTEM. 



to three days, and occasionally longer. The examination of the vomitus 
shows, as a rule, absence of the hydrochloric acid, presence of lactic and 
fatty acids, and marked increase in the mucus. 

Diagnosis. — The ordinary afebrile gastric catarrh is readily recog- 
nized. The acute febrile form is so similar to the initial symptoms of many 
of the infectious diseases that it is impossible for a day or two to make a 
definite diagnosis, particularly in the cases which have come on, so to speak, 
spontaneously and independently of an error in diet. Some of these re- 
semble closely an acute infection; the symptoms may be very intense, and 
if, as sometimes happens, the attack sets in with severe headache and de- 
lirium the case may be mistaken for meningitis. When the abdominal 
pains are intense the attack may be confounded with gallstone colic. In 
discriminating between acute febrile gastritis and the abortive forms of 
typhoid fever it is to be borne in mind that in the former the temperature 
rises abruptly, the remissions are slighter and the drop is more sudden. 
The initial bronchitis, the well-marked splenic enlargement, and the rose 
spots are not present. It is a very common error to class under gastric 
fever the mild forms of the various infectious disorders. The gastric crises 
in locomotor ataxia have in many instances been confounded with a simple 
acute gastritis, and it is always wise in adults to test the knee-jerks and 
pupillary reactions. 

Treatment. — Mild cases recover spontaneously in twenty-four hours, 
and require no treatment other than a dose of castor oil in children or of 
blue mass in adults. In the severer forms, if there is much distress in the 
region of the stomach, the vomiting should be promoted by warm water 
or the simple emetics. A full dose of calomel, 8 to 10 grains, should be 
given, and followed the next morning by a dose of Hunyadi-Janos or Carls- 
bad water. If there is eructation of acid fluid, bicarbonate of soda and 
bismuth may be given. The stomach should have, if possible, absolute 
rest, and it is a good plan in the case of strong persons, particularly in those 
addicted to alcohol, to cut off all food for a day or two. The patient may 
be allowed soda water and ice freely. It is well not to attempt to check 
the vomiting unless it is excessive and protracted. Eecovery is usually 
complete, though repeated attacks may lead to subacute gastritis or to the 
establishment of chronic dyspepsia. 

Phlegmonous Gastritis ; Acute Suppurative Gastritis. — This is an ex- 
cessively rare disease, characterized by the occurrence of suppurative pro- 
cesses in the submucosa. The affection is more common in men than in 
women. Leith has collected 85 cases, and has given the best account in 
the literature (Edinburgh Hospital Eeports, vol. iv). The cause is seldom 
obvious. It has been met with as an idiopathic affection, but it has occurred 
also in puerperal fever and other septic processes, and has occasionally 
followed trauma. Anatomically there appear to be two forms, a diffuse 
purulent infiltration and a localized abscess formation, in which case the 
tumor may reach the size of an egg, and may burst into the stomach or 
into the peritoneal cavity. In two of the cases I have seen, the abscess was 
in connection with cancer of the stomach, and it is interesting to note 
that in both there were recurring chills. In a third case, in a diffuse car* 



ACUTE GASTRITIS. 



465 



cinoma, there was extensive phlegmonous inflammation with vomiting of a 
horribly fetid material. 

The symptoms are variable. There are usually pain in the abdomen, 
fever, dry tongue, and symptoms of a severe infective process, delirium 
and coma preceding death. Jaundice has been met with in some instances. 
Occasionally, when the abscess tumor is large, it has been felt externally, 
in one case forming a mass as large as two fists. There are instances which 
run a more chronic course, with pains in the abdomen, fever, and chills. 

The diagnosis is rarely possible, even when with abscess rupture occurs, 
and the pus is vomited, as it is not possible to differentiate this condition 
from an abscess perforating into the stomach from without. It is stated, 
however, that Chvostek made the diagnosis in one of his cases. 

Toxic Gastritis. — This most intense form of inflammation of the stom- 
ach is excited by the swallowing of concentrated mineral acids or strong 
alkalies, or by such poisons as phosphorus, corrosive sublimate, ammonia, 
arsenic, etc. In the non-corrosive poisons, such as phosphorus, arsenic, 
and antimony, the process consists of an acute degeneration of the glandular 
elements, and haemorrhage. In the powerful concentrated poisons the 
mucous membrane is extensively destroyed, and may be converted into a 
brownish-black eschar. In the less severe grades there may be areas of 
necrosis surrounded by inflammatory reaction, while the submucosa is haem- 
orrhagic and infiltrated. The process is of course more intense at the 
fundus, but the active peristalsis may drive the poison through the pylorus 
into the intestine. 

The symptoms are intense pain in the mouth, throat, and stomach, 
salivation, great difficulty in swallowing, and constant vomiting, the vom- 
ited materials being bloody' and sometimes containing portions of the 
mucous membrane. The abdomen is tender, distended, and painful on 
pressure. In the most acute cases symptoms of collapse supervene; the 
pulse is weak, the skin pale and covered with sweat; there is restlessness, 
and sometimes convulsions. There may be albumin or blood in the urine, 
and petechias may develop on the skin. When the poison is less intense, 
the sloughs may separate, leaving ulcers, which too often lead, in the 
oesophagus to stricture, in the stomach to chronic atrophy, and finally to 
death from exhaustion. 

The diagnosis of toxic gastritis is usually easy, as inspection of the 
mouth and pharynx shows, in many instances, corrosive effects, while the 
examination of the vomit may indicate the nature of the poison. 

In poisoning by acids, magnesia should be administered in milk or 
with egg albumen. When strong alkalies have been taken, the dilute acids 
should be administered. If the case is seen early, lavage should be used. 
For the severe inflammation which follows the swallowing of the stronger 
poisons palliative treatment is alone available, and morphia may be freely 
employed to allay the pain. 

Diphtheritic or Membranous Gastritis. — This condition is met with 
occasionally in diphtheria, but more commonly as a secondary process in 
typhus or typhoid fever, pneumonia, pyaemia, small-pox, and occasionally 
in debilitated children. An instance of it came under my notice in pneu- 



466 



DISEASES OF THE DIGESTIVE SYSTEM. 



monia. The exudation may be extensive and uniform or in patches. The 
condition is not recognizable during life, unless, as in a case of John Thom- 
son's, the membranes are vomited. 

Mycotic and Parasitic Gastritis. — It occasionally happens that fungi 
develop in the stomach and excite inflammation. One of the most remark- 
able cases of the kind is that reported by Kundrat, in which the favus 
fungus developed in the stomach and intestine. 

In cancer and in dilatation of the stomach the sarcinae and yeast fungi 
probably aid in maintaining the chronic gastritis. As a rule, the gastric 
juice is capable of killing the ordinary bacteria. Orth states that the 
anthrax bacilli, in certain cases, produce swelling of the mucosa and ulcera- 
tion. Eug. Fraenkel has reported a case of acute emphysematous gastritis 
probably of mycotic origin. The larvae of certain insects may excite gas- 
tritis, as in the cases reported by Gerhardt, Meschede, and others. In rare 
instances tuberculosis and syphilis attack the gastric mucosa. 

II. CHRONIC GASTRITIS. 

{Chronic Catarrh of the Stomach; Chronic Dyspepsia.) 

Definition. — A condition of disturbed digestion associated with in- 
creased mucous formation, qualitative or quantitative changes in the gastric 
juice, enfeeblement of the muscular coats, so that the food is retained for 
an abnormal time in the stomach; and, finally, with alterations in the 
structure of the mucosa. 

Etiology. — The causes of chronic gastritis may be classified as fol- 
lows: (1) Dietetic. The use of unsuitable or improperly prepared food. 
The persistent use of certain articles of diet, such as very fat substances 
or foods containing too much of the carbohydrates. New England pie and 
the hot breads of the Southern States are responsible for many cases of 
chronic dyspepsia. The use in excess of tea or coffee, and, above all, of alco- 
hol in its various forms. Under this heading, too, may be mentioned the 
habits of eating at irregular hours or too rapidly and imperfectly chewing 
the food. In this country excess in eating does more damage than excess in 
drinking. A common cause of chronic catarrh is drinking too freely of ice- 
water during meals, a practice which plays no small part in the prevalence of 
dyspepsia in America. Another frequent cause is the abuse of tobacco, par- 
ticularly chewing. (2) Constitutional causes. Anaemia, chlorosis, chronic 
tuberculosis, gout, diabetes, and Bright's disease are often associated with 
chronic gastric catarrh. (3) Local conditions: (a) of the stomach, as in can- 
cer, ulcer, and dilatation, which are invariably accompanied by catarrh; (b) 
conditions of the portal circulation, causing chronic engorgement of the 
mucous membrane, as in cirrhosis, chronic heart-disease, and certain chronic 
lung affections. 

Morbid Anatomy. — Anatomically two forms of chronic gastritis 
may be recognized, the simple and the sclerotic. 

(a) Simple Chronic Gastritis. — The organ is usually enlarged, the 
mucous membrane pale gray in color, and covered with closely adherent, 



CHRONIC GASTRITIS. 



467 



tenacious mucus. The veins are large, patches of ecchymosis are not in- 
frequently seen, and in the chronic catarrh of portal obstruction and of 
chronic heart-disease small hemorrhagic erosions. Toward the pylorus the 
mucosa is not infrequently irregularly pigmented, and presents a rough, 
wrinkled, mammillated surface, the etat mammelone of the French, a con- 
dition which may sometimes be so prominent that writers have described 
it as gastritis polyposa. The membrane may be thinner than normal, and 
much firmer, tearing less readily with the finger-nail. Ewald thus de- 
scribes the histological changes: The minute anatomy shows the picture 
of a parenchymatous and an interstitial inflammation. The gland cells 
are in part eroded or show cloudy granular swelling or atrophy. The dis- 
tinction between the principal and marginal cells cannot be recognized, 
and in many places, particularly in the pyloric region, the tubes have lost 
their regular form and show in many places an atypical branching, like 
the fingers of a glove. Individual glands are cut off toward the fundus, 
but appear at the border of the submucosa as cysts, partly empty, with a 
smooth membrane, partly filled with remnants of hyaline and refractile 
epithelium. An abundant small-celled infiltration presses apart the tubules 
being particularly marked toward the surface of the mucosa, and from 
the submucosa extensions of the connective tissue may be seen passing 
between the glands. The mucoid transformation of the cells of the tubules 
is a striking feature in the process and may extend to the very fundus of 
the glands. 

(b) Sclerotic Gastritis. — As a final result of the parenchymatous and 
interstitial changes the mucous membrane may undergo complete atrophy, 
so that but few traces of secreting substance remain. There appear to 
be two forms of this sclerotic atrophy — one with thinning of the coats of 
the stomach, phthisis ventriculi, and a retention or even increase of the 
size of the organ; the other with enormous thickening of the coats and 
great reduction in the volume of the organ; the condition which is usually 
described as cirrhosis ventriculi. Extreme atrophy of the mucous mem- 
brane of the stomach has been carefully studied by Fenwick, Ewald, and 
others, and we now recognize the fact that there may be such destruction 
and degeneration of the glandular elements by a progressive development 
of interstitial tissue that ultimately scarcely a trace of secreting tissue re- 
mains. In a characteristic case, studied by Henry and myself, the greater 
portion of the lining membrane of the stomach was converted into a per- 
fectly smooth, cuticular structure, showing no trace whatever of glandular 
elements, with enormous hypertrophy of the muscularis mucosae, and here 
and there formation of cysts. In the other form, with identical atrophy 
and cyst formation, there is enormous increase in the connective tissue, and 
the stomach may be so contracted that it does not hold more than a couple 
of ounces. The walls may measure from 2 to 3 cm.; the greatest increase 
in thickness is in the submucosa, but the hypertrophy also extends to the 
muscular layers. A similar affection may coexist in the crccum and colon. 
The condition may be difficult to distinguish from diffuse carcinoma. There 
may be also proliferative peritonitis, with perihepatitis, perisplenitis, and 
ascites. While one is not justified in saying that all cases of cirrhosis of 



468 



DISEASES OF THE DIGESTIVE SYSTEM. 



the stomach represent a final stage in the history of a chronic catarrh, it is 
true that in most cases the process is associated with atrophy of the gastric 
mucosa, while the history indicates the existence of chronic dyspepsia. 

Erosions of the Stomach. — Small superficial losses of substance are met 
with in the stomach under a great variety of conditions, usually in connec- 
tion with chronic gastritis, diseases of the liver, particularly cirrhosis, and 
chronic diseases of the heart. Einhorn has described, too, a special con- 
dition in which in the washings from the fasting stomach little shreds of 
gastric mucous membrane are found, and there is tenderness and soreness on 
passing the tube and a little staining of the water. These are probably the 
result of passing the tube. True erosions are usually multiple, more com- 
mon, I think, in the pyloric region, and are usually without any symptoms. 
The mucosa in the neighborhood of the erosion may be deeply hasmor- 
rhagic. When one sees a large number of erosions, which may be present 
in some cases, it is difficult to understand why larger ulcers do not form 
at their site. The only ill effect I know of is the occurrence of profuse or 
even fatal haemorrhage. 

Symptoms. — The affection persists for an indefinite period, and, as 
is the case with most chronic diseases, changes from time to time. The 
appetite is variable, sometimes greatly impaired, at others very good. 
Among early symptoms are feelings of distress or oppression after eating, 
which may become aggravated and amount to actual pain. When the 
stomach is empty there may also be a painful feeling. The pain differs in 
different cases, and may be trifling or of extreme severity. When localized 
and felt beneath the sternum or in the precordial region it is known as 
heart-burn or sometimes cardialgia. There is pain on pressure over the 
stomach, usually diffuse and not severe. The tongue is coated, and the 
patient complains of a bad taste in the mouth. The tip and margin of the 
tongue are very often red. Associated with this catarrhal stomatitis there 
may be an increase in the salivary and pharyngeal secretions. Nausea is an 
early symptom, and is particularly apt to occur in the morning hours. It 
is not, however, nearly so constant a symptom in chronic gastritis as in 
cancer of the stomach, and in mild grades of the affection it may not occur 
at all. Eructation of gas, which may continue for some hours after taking 
food, is a very prominent feature in cases of so-called flatulent dyspepsia, 
and there may be marked distention of the intestines. With the gas, bitter 
fluids may be brought up. Vomiting, which is not very frequent, occurs 
either immediately after eating or an hour or two later. In the chronic 
catarrh of old topers a bout of morning vomiting is common, in which a 
slimy mucus is brought up. The vomitus consists of food in various stages 
of digestion and slimy mucus, and the chemical examination shows the 
presence of abnormal acids, such as butyric, or even acetic, in addition to 
lactic acid, while the hydrochloric acid, if indeed it is present, is much re- 
duced in quantity. The digestion may be much delayed, and on washing 
out the stomach as late as seven hours after eating, portions of food are 
still present. The prolonged retention favors decomposition, the stomach 
becomes distended with gas, and this, with the chronic catarrh, may induce 
gradually an atony of the muscular walls. The absorption is slow, and 



CHRONIC GASTRITIS. 



469 



iodide of potassium, given in capsules, which should normally reach the 
saliva within fifteen minutes, may not be evident for more than half an 
hour. 

Constipation is usually present, but in some instances there is diarrhoea, 
and undigested food passes rapidly through the bowels. The urine is often 
scanty, high-colored, and deposits a heavy sediment of urates. 

Of other symptoms headache is common, and the patient feels constantly 
out of sorts, indisposed for exertion, and low-spirited. In aggravated cases 
melancholia may develop. Trousseau called attention to the occurrence 
of vertigo, a marked feature in certain cases. The pulse is small, some- 
times slow, and there may be palpitation of the heart. Fever does not 
occur. Cough is sometimes present, but the so-called stomach cough of 
chronic dyspeptics is in all probability dependent upon pharyngeal irri- 
tation. 

The Gastric Contents. — The fasting stomach may be empty or it may 
contain much mucus — gastritis mucipara of Boas. In the test breakfast, 
withdrawn in an hour, the HCL is usually diminished, though it may be 
normal — gastritis acida. In other cases the free HC1 may be absent — 
gastritis anacida. While in the advanced forms of atrophy of the mucosa 
there may be neither acids nor ferments — gastritis atrophicans. 

The motor function of the stomach is not usually much impaired. 

The symptoms of atrophy of the mucous membrane of the stomach, with 
or without contraction of the organ, are very complex, and cannot be said 
to present a uniform picture. The majority of the cases present the symp- 
toms of an aggravated chronic dyspepsia, often of such severity that cancer 
is suspected. In one of the cases which I examined, the persistent distress 
after eating, the vomiting, and the gradual loss of flesh and strength, very 
naturally led to this diagnosis, but the duration of the disease far ex- 
ceeded that of ordinary carcinoma. In the cirrhotic form the tumor mass 
may sometimes be felt. In atrophy of the stomach, whether associated 
with cirrhosis or not, the clinical picture may be that of pernicious anaemia. 
As early as 1860, Flint called attention to this connection between atrophy 
of the gastric tubules and anaemia, an observation which Fenwick and 
others have amply confirmed. 

Diagnosis. — Ewald distinguishes three forms of chronic gastritis: (1) 
Simple gastritis; (2) mucous (schleimige) gastritis; (3) atrophic gastritis. 

In (1) the fasting stomach contains only a small quantity of a slimy 
fluid, while after the test breakfast the HC1 is diminished in quantity or 
may be absent. Lactic acid and the fat acids may be present. After Boasts 
more rigid test meal the organic acids are rarely found. The pepsin and 
rennet are always present. 

In (2) the acidity is always slight and the condition is distinguished 
from (1) chiefly by the large amount of mucus present. 

In (3) the fasting stomach is generally empty, while after the test 
breakfast IIC1, pepsin, and the curdling ferment are wholly wanting. 

The diagnosis of cancer of the stomach from chronic gastritis may be 
very difficult when a tumor is not present. The cases require most careful 
study, and it may take several months before 'a decision can be reached. 



470 



DISEASES OF THE DIGESTIVE SYSTEM. 



Treatment. — When possible the cause in each case should be ascer- 
tained and an attempt made to determine the special form of indigestion. 
Usually there is no difficulty in differentiating the ordinary catarrhal and 
the nervous varieties. A careful study of the phenomena of digestion in 
the way already laid down, though not essential in every instance, should 
certainly be carried out in the more obstinate and obscure forms. Two im- 
portant questions should be asked of every dyspeptic — first, as to the time 
taken at his meals; and, second, as to the quantity he eats. Practically 
a large majority of all cases of disturbed digestion come from hasty and 
imperfect mastication of the food and from overeating. Especial stress 
should be laid upon the former point. In some instances it will alone suf- 
fice to cure dyspepsia if the patient will count a certain number before 
swallowing each mouthful. The second point is of even greater impor- 
tance. People habitually eat too much, and it is probably true that a 
greater number of maladies arise from excess in eating than from excess 
in drinking. George Cheyne's thirteenth aphorism contains a volume of 
dietetic wisdom : " Every wise man, after Fifty, ought to begin to lessen 
at least the quantity of his Aliment, and if he would continue free of 
great and dangerous Distempers and preserve his Senses and Faculties clear 
to the last he ought every seven years go on abateing gradually and sensibly, 
and at last descend out of Life as he ascended into it, even into the Child's 
Diet." 

(a) General and Dietetic. — A careful and systematically arranged di- 
etary is the first, sometimes the only, essential in the treatment of a case of 
chronic dyspepsia. It is impossible to lay down rules applicable to all cases. 
Individuals differ extraordinarily in their capability of digesting different 
articles of food, and there is much truth in the old adage, " One man's food 
is another man's poison." The individual preferences for different articles 
of food should be permitted in the milder forms. Physicians have probably 
been too arbitrary in this direction, and have not yielded sufficiently to the 
intimations given by the appetite and desires of the patient. 

A rigid rhilk diet may be tried. " Milk and sweet sound Blood differ 
in nothing but in Color: Milk is Blood" (George Cheyne). In the forms 
associated with Bright's disease and chronic portal congestion, as well as in 
many instances in which the dyspepsia is part of a neurasthenic or hysterical 
trouble, this plan in conjunction with rest is most efficacious. If milk 
is not digested well it may be diluted one third with soda water or Vichy, 
or 5 to 10 grains of carbonate of soda, or a pinch of salt may be added to 
each tumblerful. In many cases the milk from which the cream has been 
taken is better borne. Buttermilk is particularly suitable, but can rarely 
be taken for so long a time alone, as patients tire of it much more readily 
than they do of ordinary milk. Not only can the general nutrition be 
maintained on this diet, but patients sometimes increase in weight, and the 
unpleasant gastric symptoms disappear entirely. It should be given at 
fixed hours and in definite quantities. A patient may take 6 or 8 ounces 
every three hours. The amount necessary varies a good deal, but at least 
3 to 5 pints should be given in the twenty-four hours. This form of diet is 
not, as a rule, well borne wnen there is a tendency to dilatation of the 



CHRONIC GASTRITIS. 



471 



stomach. The milk may be previously peptonized, but it is impossible to 
feed a chronic dyspeptic in this way. The stools should be carefully 
watched, and if more milk is taken than can be digested it is well to supple- 
ment the diet with eggs and dry toast or biscuits. 

In a large proportion of the cases of chronic indigestion it is not neces- 
sary to annoy the patient with such strict dietaries. It may be quite suf- 
ficient to cut off certain articles of food. Thus, if there are acid eructations 
or flatulency, the farinaceous foods should be restricted, particularly pota- 
toes and the coarser vegetables. A fruitful source of indigestion is the 
hot bread which, in different forms, is regarded as an essential part of an 
American breakfast. This, as well as the various forms of pancakes, pies 
and tarts, with heavy pastry, and fried articles of all sorts, should be strictly 
forbidden. As a rule, white bread, toasted, is more readily digested than 
bread made from the whole meal. Persons, however, differ very much in 
this respect, and the Graham or brown bread is for many people most 
digestible. Sugar and very sweet articles of food should be taken in great 
moderation or avoided altogether by persons with chronic dyspepsia. Many 
instances of aggravated indigestion have come to my notice due to the 
prevalent practice of eating largely of ice-cream. One of the most powerful 
enemies of the American stomach in the present day is the soda-water 
fountain, which has usurped so important a place in the apothecary shop. 

Fats, with the exception of a moderate amount of good butter, very 
fat meats, and thick, greasy soups should be avoided. Kipe fruit in modera- 
tion is often advantageous, particularly when cooked. Bananas are not, as 
a rule, well borne. Strawberries are to many persons a cause of an annual 
attack of indigestion and sore throat in the spring months. 

As stated, in the matter of special articles of food it is impossible to 
lay down rigid rules, and it is the common experience that one patient 
with indigestion will take with impunity the very articles which cause the 
greatest distress to another. 

Another detail of importance which may be mentioned in this con- 
nection is the general hygienic management of dyspeptics. These pa- 
tients are often introspective, dwelling in a morbid manner on their symp- 
toms, and much inclined to take a despondent view of their condition. 
Very little progress can be made unless the physician gains their confidence 
from the outset. Their fears and whims should not be made too light of 
or ridiculed. Systematic exercise, carefully regulated, particularly when, 
as at watering places, it is combined with a restricted diet, is of special 
service. Change of air and occupation, a prolonged sea voyage, or a summer 
in the mountains will sometimes cure the most obstinate dyspepsia. 

(1>) Medicinal — The special therapeutic measures may be divided into 
those which attempt to replace in the digestive juices important elements 
which are lacking and those which stimulate the weakened action of the 
organ. In the first group come the hydrochloric acid and ferments, which 
are so freely employed in dyspepsia. The former is the most important. 
It is the ingredient in the gastric juice most commonly deficient. It is not 
only necessary for its own important actions, but its presence is intimately 
associated with that of the pepsin, as it is only in the presence of a suffi- 



472 



DISEASES OF THE DIGESTIVE SYSTEM. 



cient quantity that the pepsinogen is converted into the active digestive 
ferment. It is best given as the dilute acid taken in somewhat larger quan- 
tities than are usually advised. Ewald recommends large doses — of from 
90 to 100 drops — at intervals of fifteen minutes after the meals. Leube 
and Eiegel advise smaller doses. Probably from 15 to 20 drops is sufficient. 
The prolonged use of it does not appear to be in any way hurtful. The use, 
however, should be restricted to cases of neurosis and atrophy of the mucous 
membrane. In actual gastritis its value is doubtful. 

Nitrate of silver is a good remedy in some cases, used in solution in 
the lavage (1 to 1,500 or 1 to 2,000), or in pill form, one eighth to one 
fourth of a grain three times a day. For many years Pepper has advocated 
the more extended use of this drug in chronic gastritis. I have seen an 
instance of argyria after its protracted use. 

The digestive ferments: These are extensively employed to strengthen 
the weakened gastric and intestinal secretions. The use of pepsin, ac- 
cording to Ewald, may be limited to the cases of advanced mucous catarrh 
and the instances of atrophy of the stomach, in which it should be given, 
in doses of from 10 to 15 grains, with dilute hydrochloric acid a quarter 
of an hour after meals. It may be used in various different forms, either 
as a powder or in solution or given with the acid. The powder is much 
more certain. Pepsin wine is generally inert, as there is little of the fer- 
ment taken up by alcohol. It is important to use a reliable article. Much 
that is in the market is valueless. 

Pancreatin is of equal or even greater value than the pepsin. Pains 
should be taken to use a good article, such as that prepared by Merck. It 
should be given in doses of from 15 to 20 grains, in combination with 
bicarbonate of soda. It is conveniently administered in tablets, each of 
which contains 5 grains of the pancreatin and the soda, and of these two 
or three may be taken fifteen or twenty minutes after each meal. Ptyalin 
and diastase are particularly indicated when the acid is excessive. The 
action of the former continues in the stomach during normal digestion. 
The malt diastase is often very serviceable given with alkalies. 

Of measures which stimulate the glandular activity in chronic dys- 
pepsia lavage is by far the most important, particularly in the forms char- 
acterized by the secretion of a large quantity of mucus. Luke-warm water 
should be used, or, if there is much mucus, a 1-per-cent salt solution, or 
a 3- to 5-per-cent solution of bicarbonate of soda. If there is much fer- 
mentation the 3-per-cent solution of boric acid may be used, or a dilute 
solution of carbolic acid. It is best employed in the morning on an empty 
stomach, or in the evening some hours after the last meal. It is perhaps 
preferable in the morning, except in those cases in which there is much 
nocturnal distress and flatulency. Once a day is, as a rule, sufficient, or, 
in the case of delicate persons, every second day. The irrigation may be 
continued until the water which comes away is quite clear. It is not neces- 
sary to remove all the fluid after the irrigation. 

While perhaps in some hands this measure has been carried to ex- 
tremes, it is one of such extraordinary value in certain cases that it should 
be more widely employed by practitioners. When there is an insuperable 



CHRONIC GASTRITIS. 



473 



objection to lavage a substitute may be used in the form of warm alka- 
line drinks, taken slowly in the early morning or the last thing at 
night. 

Of medicines which stimulate the gastric secretion the most important 
are the bitter tonics, such as quassia, gentian, calumba, cundurango, ipecacu- 
anha, strychnia, and cardamoms. These are probably of more value in 
chronic gastritis than the hydrochloric acid. Of these strychnia is the most 
powerful, though none of them have probably any very great stimulating 
action on the secretion, and influence rather the appetite than the diges- 
tion. Of stomachics which are believed to favorably influence digestion 
the most important are alcohol and common salt. The former would appear 
to act in moderate quantities by increasing the acid in the gastric juice, and 
with it probably the pepsin formation. Others hold that it is not so much 
the secretory as the motor function of the stomach which the alcohol 
stimulates. In moderate quantities it "has certainly no directly injurious 
influence on the digestive processes. Special care should be taken, how- 
ever, in ordering alcohol to dyspeptics. If a patient has been in the habit 
of taking beer or light wines or stimulants with his meals, the practice 
may be continued if moderate quantities are taken. Beer, as a rule, is not 
well borne. A dry sherry or a class of claret is preferable. In the case of 
women with any form of dyspepsia stimulants should be employed with 
the greatest caution, and the practitioner should know his patient well 
before ordering alcohol. 

The importance of salt in gastric digestion rests upon the fact that its 
presence is essential in the formation of the hydrochloric acid. An in- 
crease in its use may be advised in all cases of chronic dyspepsia in which 
the acid is defective. 

Treatment of Special Conditions. — Fermentation and flatu- 
lency. When the digestion is slow or imperfect, fermentation goes on in 
the contents, with the formation of gas and the production of lactic, butyric, 
and acetic acids. For the treatment of this condition careful dieting may 
suffice, particularly forbidding such articles as tea, pastry, and the coarser 
vegetables. It is usually combined with pyrosis, in which the acid fluids 
are brought into the mouth. Bismuth and carbonate of soda sometimes 
suffice to relieve the condition. Thymol, creasote, and carbolic acid may 
be employed. For acid dyspepsia Sir William Eoberts recommends the 
bismuth lozenge of the British Pharmacopoeia, the antacid properties of 
which depend on chalk and bicarbonate of soda. It should be taken an 
hour or two after meals, and only when the pain and uneasiness are pres- 
ent. The burnt magnesia is also a good remedy. Glycerin in from 20- to 
60-minim doses, the essential oils, animal charcoal alone or in combination 
with compound cinnamon powder, may be tried. If there is much pain, 
chloroform in 20-minim doses or a teaspoonfnl of Hoffman's anodyne may 
be used. In obstinate cases lavage is indicated and is sometimes striking in 
its effects. Alkaline solutions may be used. 

Vomiting is not a feature which often calls for treatment in chronic 
dyspepsia; sometimes in children it is a persistent symptom. Creasote and 
carbolic acid in drop doses, a few drops of chloroform or of dilute hydro- 



474 



DISEASES OF THE DIGESTIVE SYSTEM. 



cyanic acid, cocaine, bismuth, and oxalate of cerium may be used. If 
obstinate, the stomach should be washed out daily. 

Constipation is a frequent and troublesome feature of most forms of 
indigestion. Occasionally small doses of mercury, podophyllin, the laxative 
mineral waters, sulphur, and cascara may be employed. Glycerin sup- 
positories or the injection of from half a teaspoonful to a teaspoonful of 
glycerin is very efficacious. 

Many cases of chronic dyspepsia are greatly benefited by the use of 
mineral waters, particularly a residence at the springs with a careful super- 
vision of the diet and systematic exercise. The strict regime of certain 
German Spas is particularly advantageous in the cases in which the chronic 
dyspepsia has resulted from excess in eating and in drinking. Kissingen, 
Carlsbad, Ems, and Wiesbaden are to be specially recommended. 



III. DILATATION OF THE STOMACH (Oastrectasis). 

Etiology. — This may occur either as an acute or a chronic condition. 

Acute dilatation is rarely seen, though it occurs whenever enormous 
quantities of food and drink are quickly ingested. Occasionally this leads 
to extreme paralytic dilatation, and Fagge has described two cases which 
came on in this way, one of which proved fatal. Allbutt mentions a re- 
markable instance of acute dilatation of the stomach under the care of 
Broadbent, in which 8 pints of fluid were siphoned from the stomach. " ~No 
sooner, however, was this volume of fluid removed than the stomach began 
to refill, and was rapidly distended again to its former dimensions/' 

Chronic dilatation results from: (a) Narrowing of the pylorus or of the 
duodenum by the cicatrization of an ulcer, hypertrophic stenosis of the 
pylorus (whether cancerous or simple), congenital stricture, or occasionally 
by pressure from without of a tumor or of a floating kidney. Without any 
organic disease the pylorus may be tilted up by adhesion to the liver or 
gall-bladder, or the stomach may be so dilated that the pylorus is dragged 
down and kinked, (b) Eelative or absolute insufficiency of the muscular 
power of the stomach, due on the one hand to repeated overfilling of the 
organ with food and drink (Ueberanstrengung des Magens, Striimpell), 
and on the other to atony of the coats induced by chronic inflammation or 
degeneration of impaired nutrition, the result of constitutional affections, 
as cancer, tuberculosis, anaemia, etc. 

It is important to distinguish between a dilated stomach and a dis- 
placed organ, which will be considered under the section on enteroptosis. 

The most extreme forms are met with in the first group, and most 
commonly as a sequence of the cicatricial contraction of an ulcer. There 
may be considerable stenosis without much dilatation, the obstruction being 
compensated by hypertrophy of the muscular coats. Considerable atten- 
tion has been directed in Germany by Litten, Ewald, and others to the 
association of dilatation with dislocation of the right kidney. 

In the second group, due to atony of the muscular coats, we must dis- 
tinguish between instances in which the stomach is simply enlarged and 



DILATATION OF THE STOMACH. 



475 



those with actual dilatation, the conditions which Ewald characterized as 
megastrie and gastrectasis respectively. The size of the stomach varies 
greatly in different individuals, and the maximum capacity of a normal 
organ Ewald places at about 1,600 cc. Measurements above this point in- 
dicate absolute dilatation. 

Atonic dilatation of the stomach may result from weakness of the coats, 
due to repeated overdistention or to chronic catarrh of the mucous mem- 
brane, or to the general muscular debility which is associated with chronic 
wasting disorders of all sorts. The combination of chronic gastric catarrh 
with overfeeding and excessive drinking is one of the most fruitful sources 
of atonic dilatation, as pointed out by Naunyn. The condition is fre- 
quently seen in diabetics, in the insane, and in beer-drinkers. In Germany 
this form is very common in men employed in the breweries. Possibly 
muscular weakness of the coats may result in some cases from disturbed 
innervation. Dilatation of the stomach is most frequent in middle-aged 
or elderly persons, but the condition is not uncommon in children, espe- 
cially in association with rickets. 

Symptoms. — These are very variable and depend upon the cause and 
the degree of dilatation. Naturally the features in cancer of the pylorus 
would be very different from those met with in an excessive drinker. Dys- 
pepsia is present in nearly all cases, and there are feelings of distress and 
uneasiness in the region of the stomach. The patient may complain much 
of hunger and thirst and eat and drink freely. The most characteristic 
symptom is the vomiting at intervals of enormous quantities of liquid and 
of food, amounting sometimes to four or more litres. The material is often 
of a dark-grayish color, with a characteristic sour odor clue to the organic 
acids present, and contains mucus and remnants of food. On standing it 
separates into three layers, the lowest consisting of food, the middle of 
a turbid, dark-gray fluid, and the uppermost of a brownish froth. The 
microscopical examination shows a large variety of bacteria, yeast fungi, 
and the sarcina ventriculi. There may also be cherry stones, plum stones, 
and grape seeds. 

The hydrochloric acid may be absent, diminished, normal, or in excess, 
depending upon the cause of the dilatation. The fermentation produces 
lactic, butyric, and, possibly, acetic acid and various gases. 

In consequence of the small amount of fluid which passes from the 
stomach or is absorbed there are constipation, scanty urine, and extreme 
dryness of the skin. The general nutrition of the patient suffers greatly; 
there is loss of flesh and strength, and in some cases the most extreme 
emaciation. A very remarkable symptom which occurs occasionally is 
tetany, first described by Kussmaul. 

Physical Signs. — Inspection. — The abdomen may be large and promi- 
nent, the greatest projection occurring below the navel in the standing 
posture. In some instances the outline of the distended stomach can be 
plainly seen, the small curvature a couple of inches below the ensiform 
cartilage, and the greater curvature passing obliquely from the tip of the 
tenth rib on the left side, toward the pubes, and then curving upward to 
the right costal margin. Too much stress cannot be laid on the importance 



476 



DISEASES OF THE DIGESTIVE SYSTEM. 



of inspection. In 10 of 13 cases of dilated stomach in my wards during 
one year the diagnosis was made de visu. Active peristalsis may be seen 
in the dilated organ, the waves passing from left to right. Occasionally 
anti-peristalsis may be seen. In cases of stricture, particularly of hyper- 
trophic stenosis, as the peristaltic wave reaches the pylorus, the tumor- 
like thickening can sometimes be distinctly seen through the thin ab- 
dominal wall. To stimulate the peristalsis the abdomen may be flipped 
with a wet towel. Inflation may be practised with carbonic-acid gas. 
A small teaspoonful of tartaric acid dissolved in an ounce of water is 
first given, then a rather larger quantity of bicarbonate of soda. In 
many cases, particularly in thin persons, the outline of the dilated stom- 
ach stands out with great distinctness, and waves of peristalsis are seen 
in it. 

Palpation. — The peristalsis may be felt, and usually in stenosis the 
tumor is evident at the pylorus. The resistance of a dilated stomach is 
peculiar, and has been aptly compared to that of an air cushion. Biman- 
ual palpation elicits a splashing sound — clapotage — which is, of course, not 
distinctive, as it can be obtained whenever there is much liquid and air 
in the organ, but which cannot be elicited in a healthy person two or three 
hours after eating. The splashing may be very loud, and the patient may 
produce it himself by suddenly depressing the diaphragm, or it may be 
readily obtained by shaking him. A tube passed into the stomach may 
be felt externally through the skin, a procedure no longer recommended by 
Leube, who suggested it. The gurgling of gas through the pylorus may 
be felt. 

Percussion. — The note is tympanitic over the greater portion of a 
dilated stomach; in the dependent part the note is dull. In the upright 
position the percussion should be made from above downward, in the left 
parasternal line, until a change in resonance is reached. The line of this 
should be marked, and the patient examined in the recumbent position, 
when it will be found to have altered its level. When this is on a line with 
the navel or below it, dilatation of the stomach may generally be assumed 
to exist. The fluid may be withdrawn from the stomach with a tube, and 
the dulness so made to disappear, or it may be increased by pouring in more 
fluid. In cases of doubt the organ should be artificially distended with 
carbonic-acid gas in the manner described above. The most accurate 
method of determining the size of the stomach is by inflation through a 
stomach-tube with a Davidson's syringe. Pacanowski has shown that the 
greatest vertical diameter of gastric resonance in the normal stomach varies 
from 10 to 14 cm. in the male and is about 10 cm. in the female. 

Auscultation. — The clapotement or succussion can be obtained readily. 
Frequently a curious sizzling sound is present, not unlike that heard when 
the ear is placed over a soda-water bottle when first opened. It can be 
heard naturally, and is usually evident when the artificial gas is being 
generated. The heart sounds may sometimes be transmitted with great 
clearness and with a metallic quality. 

Mensuration may be used by passing a hard sound into the stomach 
until the greater curvature is reached. Normally it rarely passes more 



DILATATION OF THE STOMACH. 



477 



than 60 cm., measured from the teeth, but in cases of dilatation it may 
pass as much as 70 cm. 

Diagnosis. — The diagnosis can usually be made without much diffi- 
culty. I would like to emphasize again the great value of inspection, partic- 
ularly in combination with inflation of the stomach with carbonic-acid gas. 
Curious errors, however, are on record, one of the most remarkable of which 
was the confounding of dilated stomach with an ovarian cyst; even after 
tapping and the removal of portions of food and fruit seeds, abdominal 
section was performed and the dilated stomach opened. I notice the report 
of a recent case in which the diagnosis of ascites was made and the abdomen 
was opened. The prognosis is bad in cases in which there is stenosis of the 
pylorus, either simple or cancerous. 

Treatment. — In the cases due to atony careful regulation of the 
diet and proper treatment of the associated catarrh will suffice to effect a 
cure. Strychnine, ergot, and iron are recommended. Washing out the 
stomach is of great service, though we do not see such striking and imme- 
diate results in this form. In cases of mechanical obstruction the stomach 
should be emptied and thoroughly washed, either with warm water or with 
an antiseptic solution. We accomplish in this way three important things: 
We remove the weight, which helps to distend the organ; we remove the 
mucus and the stagnating and fermenting material which irritates and in- 
flames the stomach and impedes digestion; and we cleanse the inner sur- 
face of the organ by the application of water and medicinal substances. 
The patient can usually be taught to wash out his own stomach, and in a 
case of dilatation from simple stricture I have known the practice to be 
followed daily for three years with great benefit. The rapid reduction in 
the size of the stomach is often remarkable, the vomiting ceases, the food 
is taken readily, and in many cases the general nutrition improves rapidly. 
As a rule, once a day is sufficient, and it may be practised either the first 
thing in the morning or before going to bed. So soon as the fermentative 
processes have been checked lukewarm water alone should be used. 

The food should be taken in small quantities at frequent intervals, and 
should consist of scraped beef, Leube's beef solution, and tender meats 
of all sorts. Fatty and starchy articles of diet are to be avoided. Liquids 
should be taken sparingly. 

When the condition becomes aggravated a resort to surgery is justifi- 
able. Here may be mentioned the recent statistics of gastric surgery. 
Pyloric stenosis is the common condition. Dreydorff has collected 442 
cases — 188 cases of pylorectomy, mortality 57.4 per cent; 215 gastroenter- 
ostomies, mortality 43.3 per cent; pyloroplasty, 29 cases, mortality 20.7 
per cent. On an average, after pylorectomy the patient remained free from 
recurrence for a little over a year. 



478 



DISEASES OF THE DIGESTIVE SYSTEM. 



IV. THE PEPTIC ULCER-GASTRIC AND DUODENAL. 

The round, perforating, or simple nicer is usually single, and occurs 
in the stomach and in the duodenum as far as the papilla biliaria. It fol- 
lows nutritional disturbance in a limited region of the mucosa, which re- 
sults in the gradual destruction of this area by the gastric juice. The con- 
dition is usually associated with superacidity. 

Etiology. — Incidence in the Post-mortem Boom. — The statistics of 
W. H. Welch give 5 per cent of ulcer, open or cicatrized, a figure which 
Bramwell thinks high for the general population in Great Britain. Others 
give percentages as high as 10. The scars are more frequent than the 
open ulcers. Among the first thousand autopsies at the Johns Hopkins 
Hospital there were 9 cases of ulcer of the stomach. 

Incidence Clinically. — The disease is much less common in some coun- 
tries than in others, and in some parts of this country. It is certainly less < 
frequently seen in Baltimore than in Massachusetts or in Canada. In nine 
years there were in my wards only 25 instances with a diagnosis of ulcer. 

Sex. — Of 1,699 cases collected from hospital statistics by W. H. Welch 
and examined post mortem, 40 per cent were in males and 60 per cent were 
in females. 

Age. — In females the largest number of cases occurs between twenty 
and thirty; in males between thirty and forty. It is by no means uncom- 
mon in old people. On the other hand, it is not very rare in children. 
Goodhart reported a case in an infant thirty hours old; indeed, ulcers of 
the stomach have been found in the foetus and in the new-born shortly 
after birth. In 390 autopsies at the Baby's Hospital in New York, Martha 
Wollstein found 5 cases. 

Heredity appears to play a part in some cases (Dreschfeld). 

Occupation. — Servant girls seem particularly prone to the disease. This 
is to be explained partly by their careless habits in eating, partly in connec- 
tion with the associated anaemia. The special liability of shoemakers, weav- 
ers, and tailors to ulcer is probably connected, as Habershon suggested, with 
pressure on the stomach. 

Trauma. — Ulcers have been known to follow a blow in the region of 
the stomach. Easmussen holds that pressure of the costal margin from 
various causes induces anaemia and atrophy of the mucous membrane, par- 
ticularly in the region of the smaller curvature. 

Associated Diseases. — Anaemia and chlorosis predispose strongly to gas- 
tric ulcer, particularly in women and in association with menstrual dis- 
orders. A very considerable number of all cases of gastric ulcer occur in 
chlorotic girls. It has been found also in connection with disease of the 
heart, arterio-sclerosis, and disease of the liver. The tuberculous and syph- 
ilitic ulcers of the stomach have already been considered. 

The duodenal ulcer is less common than the gastric ulcer, and occurs 
most frequently in males. The combined statistics of Krauss, Chvostek, 
Lebert, and Trier give 171 cases in males and 39 in females. In 9 of my 
cases 7 were in males and 2 in females; one of these was in a lad of twelve. 



THE PEPTIC ULCER— GASTRIC AND DUODENAL. 479 



It has been found in association with tuberculosis, and may follow large 
superficial burns. Perry and Shaw found it five times in 149 autopsies in 
cases of burns. 

Morbid Anatomy. — Though usually single, the ulcers may be mul- 
tiple. In none of my cases were there more than five, but there is an in- 
stance on record of thirty-four. The ulcer is situated most commonly on 
the posterior wall of the pyloric portion at or near the lesser curvature. It 
is not nearly so frequent on the anterior wall. Of 793 cases collected by 
Welch from hospital statistics, 288 were on the lesser curvature, 235 on 
the posterior Avail, 95 at the pylorus, 69 on the anterior wall, 50 at the 
cardia, 29 at the fundus, 27 on the greater curvature. The duodenal ulcer 
is usually situated just outside the ring in the first portion of the gut. 

Acute and chronic forms of gastric ulcer may be described. The former 
is usually small, punched out, the edges clean-cut, the floor smooth, and 
the peritoneal surface not thickened. The chronic ulcer is of larger size, 
the margins are no longer sharp, the edges are indurated, and the border 
is sinuous. The gastric ulcer sometimes reaches an enormous size. The 
largest of which I have any knowledge is one reported by Peabody, which 
measured 19 by 10 cm. and involved all of the lesser curvature and spread '" 
over a large part of the anterior and posterior walls. The sides are often 
terraced. The floor is formed either by the submucosa, by the muscular 
layers, or, not infrequently, by the neighboring organs, to which the stom- 
ach has become attached. In the healing of the ulcer, if the mucosa is 
alone involved, the granulation tissue develops from the edges and the 
floor and the newly formed tissue gradually contracts and unites the mar- 
gins, leaving a smooth scar. In larger ulcers which have become deep and 
involved the muscular coat the cicatricial contraction may cause serious 
changes, the most important of which is narrowing of the pyloric orifice 
and consequent dilatation of the stomach. In the case of a girdle ulcer, 
hour-glass contraction of the stomach may be produced. It is probable 
that large ulcers persist for years without any attempt at healing. 

Among the more serious changes which may proceed in an ulcer are 
the following: 

Perforation. — Fortunately, in a majority of the cases, adhesions form 
between the stomach and adjacent organs, particularly with the pancreas, 
the left lobe of the liver, and the omental tissues. On the anterior surface 
of the stomach adhesions do not so readily form, hence the great danger 
of the ulcer in this situation, which more readily perforates and excites a 
diffuse and fatal peritonitis. On the posterior wall the ulcer penetrates 
directly into the lesser peritoneal cavity, in which case it may produce an 
air-containing abscess with the symptoms of the condition known as sub- 
phrenic pyo-pneumothorax. In rare instances adhesions and a gastro- 
cutanoous fistula form, usually in the umbilical region. Fistulous com- 
munication with the colon may also occur, or a gastro-duodenal fistula. 
The pericardium may be perforated, and even the left ventricle. Perfora- 
tion into the pleura may also occur. It is to be noted that general em- 
physema of the subcutaneous tissues occasionally follows perforation of a 
gastric ulcer. 

30 



480 



DISEASES OF THE DIGESTIVE SYSTEM. 



Erosion of Blood-vessels. — The haemorrhage may occur in the acutely 
formed ulcer or in the ulceration which takes place at the base of the chronic- 
form; it is in the latter condition that the bleeding is most common. Ulcers, 
on the posterior wall may erode the splenic artery, but perhaps more fre- 
quently the bleeding proceeds from the artery of the lesser curve. In the. 
case of duodenal ulcer the pancreatico-duodenal artery may be eroded or 
(as in one of my cases) fatal haemorrhage may result from the opening of 
the hepatic artery, or more rarely the portal vein. Interesting changes occur 
in the vessels. Embolism of the artery supplying the ulcerated region has 
been met with in several cases; in others diffuse endarteritis. SmalL 
aneurisms have been found in the floor of the ulcers by Douglas Powell,, 
Welch, and others. 

Cicatrization. — Superficial ulcers often heal without leaving any seri- 
ous damage. Stenosis of the pyloric orifice not infrequently follows the^ 
healing of an ulcer in its neighborhood. In other instances the large an- 
nular ulcer may cause in its cicatrization an hour-glass contraction of the' 
stomach. The adhesion of the ulcer to neighboring parts may subsequently 
be the cause of much pain. The parts of the mucosa in the neighborhood of 
"'the ulcer frequently show signs of chronic gastritis. 

The origin of the peptic ulcer is still obscure. Ulcers have been pro- 
duced in animals in many ways, both by artificial emboli and by direct 
chemical and mechanical irritants applied to the mucosa. The ulcers thus, 
produced heal with great rapidity unless the animals have been rendered 
anaemic by repeated abstraction of blood. Virchow's view that the process, 
may result from plugging the nutrient artery of the part, either by an 
embolus or by a thrombus, and that the infarct so produced is destroyed by 
the gastric juice, has gained general acceptance. It is in conformity with 
Pavy's well-known experiments and with the anatomical facts already men- 
tioned, particularly with the funnel-like shape of the ulcer, and the actuaL 
demonstration, in some cases, of the plugged vessels; but this view scarcely 
meets all the cases, in many of which the etiology is still obscure. Mere 
mechanical injury to the mucous membrane is, however, in most cases, in- 
sufficient cause for an ulcer, for normally the stomach is perfectly able 
to withstand such insults. Ewald concludes that certain predisposing 
causes play an important role in its development. He points to its fre- 
quency in conditions of amenorrhcea, chlorosis, anaemia after confinements, 
etc., where one may assume that the condition of the blood is not wholly 
normal, and also to the fact that in the majority of cases of this affection 
there is a superacidity of the gastric juice. One or both of these predis- 
posing factors seem to be present in most cases, and it has been recently 
shown that in the various anaemiae there is an appreciable diminution in 
the normal alkalinity of the blood, a fact which tends to explain one of 
the predisposing causes in these affections, and which is in accord with the 
" alkalescence theory " of Cohnheim. Of late the view has been advanced, 
particularly by Letulle and by Sydney Martin, that the ulceration is due 
to a bacterial necrosis of the gastric mucosa, and the latter suggests that the 
frequency of the ulcer at the pyloric region is associated with the absence 
of the glands at this part, which form the hydrochloric acid. The duo- 



THE PEPTIC ULCER— GASTRIC AND DUODENAL. 



481 



denal ulcer has an identical origin, but a few cases of acute ulcer, as 
already mentioned, have a curious relation with superficial burns. Bar- 
deen's researches upon the necroses in the viscera following extensive burns 
throw an important light upon these cases, showing especially how the 
gastro-intestinal mucous membrane is implicated in the toxic effects. In 
one of my cases there was an ulcer in the posterior wall of the duodenum, 
1.5 cm. in diameter, with overlapping edges, and not far from it was a 
cyst-like cavity in the submucosa associated with Brunner's glands, and it 
is possible that the open ulcer, with undermined edges, resulted from the 
rupture of one of these cysts. 

Symptoms. — The condition may be met with accidentally, post mor- 
tem. The first symptoms may be those of perforation. In other cases again, 
for months and years, the patient has had dyspepsia, and the ulcer may 
not have been suspected until the occurrence of a sudden haemorrhage. 

The symptoms suggestive of peptic ulcer are: (a) Dyspepsia, which may 
be slight and trifling or of a most aggravated character. In a considerable 
proportion of all cases nausea and vomiting occur, the latter not for two 
or more hours after eating. The vomitus usually contains a large amount 
of HC1. 

(b) Haemorrhage is present in at least one half of all cases. It may be 
slight, but more commonly is profuse, and may be in such quantities and 
brought up so quickly that it is fluid, bright red in color, and quite un- 
altered. When the blood remains for some time in the stomach and is 
mixed with food it may be greatly changed, but the vomiting of a large 
quantity of unaltered blood is very characteristic of ulcer.' Syncope or con- 
vulsions may follow; death rarely results directly from the haemorrhage. A 
most extreme grade of anaemia may be produced. Hemiplegia and amau- 
rosis with optic atrophy may follow the profuse haemorrhage. In either 
the gastric or duodenal ulcer, more commonly in the latter, the blood may be 
passed in the stools and not be vomited. This may occur when the haem- 
orrhage is slight, but also when it is profuse enough to produce collapse 
and extreme anaemia. Profuse, even fatal, haemorrhage may come from 
small, superficial ulcers, or even from the haemorrhagic erosions. Prob- 
ably it is from such that in elderly persons profuse haemorrhage occurs 
without previous gastric symptoms. 

(c) Pain is perhaps the most constant and distinctive feature of ulcer. 
It varies greatly in character; it may be only a gnawing or burning sensa- 
tion, which is particularly felt when the stomach is empty, and is relieved 
by taking food, but the more characteristic form comes on in paroxysms 
of the most intense gastralgia, in which the pain is not only felt in the 
epigastrium, but radiates to the back and to the sides. In many eases the 
two points of epigastric pain and dorsal pain, about the level of the tenth 
dorsal vertebra, are very well marked. These attacks are most frequently 
induced by taking food, and they may recur at a variable period after eat- 
ing, sometimes within fifteen or twenty minutes, at others as late as two 
or three hours. It is usually stated that when the ulcer is near the cardia 
the pain is apt to set in earlier, but there is no certainty on this point. In 
some cases it comes on in the early morning hours. The attacks may 



482 



DISEASES OF THE DIGESTIVE SYSTEM. 



occur at intervals with great intensity for weeks or months at a time, so that 
the patient constantly requires morphia, then again they may disappear 
entirely for a prolonged period. In the attack the patient is usually bent 
forward, and finds relief from pressure over the epigastric region; one 
patient during the attack would lean over the back of a chair; another 
would lie flat on the floor, with a hard pillow under the abdomen. Pres- 
sure is, as a rule, grateful. It has been thought that the posture assumed 
during the attack would indicate the site of the ulcer, but this is very 
doubtful. 

(d) Tenderness on pressure is a common symptom in ulcer, and patients 
weir the waist-band very low. Pressure should be made with great care, 
as rupture of an ulcer is said to have been induced by careless manipulation. 

(e) In old ulcers with thickened bases an indurated mass can usually be 
felt in the neighborhood of the pylorus. 

(/) Of general symptoms, loss of iveiglit results from the prolonged dys- 
pepsia, but it rarely, except in association with cicatricial stenosis of the 
pylorus, reaches the high grade met with in cancer. The ancemia may be 
extreme, and in one case of duodenal ulcer, which I examined, the blood- 
count was as low as 700,000 per c. mm. There are instances, such as the 
one reported by Pepper and Griffith, in which the extreme anaemia can not 
be explained by the occurrence of haemorrhage. In a few cases parotitis 
occurs. In one of my cases there was a remarkable pigmentation of the 
face and of the axillary folds. 

(g) Perforation. — This occurs in about 6-| per cent of all cases. The 
acute, perforating forms is much more common in women than in men. 
The symptoms are those of perforative peritonitis. Particular attention 
must be given to this accident since it has come so successfully within the 
sphere of the surgeon. As already mentioned, perforation may take place 
either into the lesser peritonaeum or into the general peritoneal cavity, in 
both of which cases operation is indicated; in rare instances the ulcer may 
perforate the pericardium. This was the case in 10 of 28 cases in which the 
diaphragm was perforated (Pick). 

Localized, more frequently subphrenic, abscess may follow perforation. 

The course of the disease is, in the majority of cases, chronic. Only a 
few instances run a very acute course. The following group of clinical 
forms, described by Welch, indicate the diversity of this affection: 

" 1. Latent ulcers, with entire absence of symptoms, and revealed as 
open ulcers or as cicatrices at the autopsy. 

" 2. Acute perforating ulcers. With or without a period of brief gas- 
tric disturbance, perforation occurs and causes speedy death. 

" 3. Acute hemorrhagic form of gastric ulcer. After a latent or a 
brief course of the ulcer, profuse gastrorrhagia occurs, which may termi- 
nate fatally or may be followed by the symptoms of chronic ulcer. 

" 4. Gastralgic-dyspeptic form. In this, which is the most common 
form of gastric ulcer, gastralgia, dyspepsia, and vomiting are the symptoms. 
Sometimes one of the symptoms predominates greatly over the others, so 
that Lebert distinguishes separately a gastralgic, a dyspeptic, and a vomit- 
ive variety. Gastralgia is the most frequent symptom. 



THE PEPTIC ULCER— GASTRIC AND DUODENAL. 



4S3 



" 5. Chronic hemorrhagic form. Gastrorrhagia is a marked symptom, 
and occurs usually in combination with the symptoms just mentioned. 

" 6. Cachectic form. This usually corresponds only to the final stage 
of one of the preceding forms, but the cachexia may develop so rapidly 
and become so marked that the course of the disease closely resembles that 
of gastric cancer. 

" 7. Eecurrent form. In this the symptoms of gastric ulcer disappear, 
and then follow intervals, often of considerable duration, in which there 
is apparent cure, but the symptoms return, especially after some indiscre- 
tion in the mode of living. This intermittent course may continue for 
many years. In these cases it is probable either that fresh ulcers form or 
that the cicatrix of an old ulcer becomes ulcerated. 

" 8. Stenotic form. By the formation of cicatricial tissue in and around 
the ulcer, the pyloric orifice becomes obstructed and the symptoms of dila- 
tation of the stomach develop/' And to this may be added the form in 
which cancer develops, which will be referred to later. 

The course may be very protracted, and there are cases in which the 
disease has persisted for over twenty years. I have reported two instances 
of peptic ulcer, probably duodenal, in which well-marked symptoms were 
present, in one case for eighteen, and in the other for twelve years. Both 
were of the chronic hemorrhagic form. 

Diagnosis. — The recognition of gastric ulcer is in many cases easy, 
as the combination of dyspepsia, gastralgic attacks, and hsematemesis is 
very characteristic. Of the symptoms, hemorrhage with the gastralgic 
attack is the most characteristic- The distinctions between ulcer and can- 
cer will be given later. The greatest difficulty is offered by certain cases 
of gastralgia, which may resemble ulcer very closely, as, with the exception 
of the haemorrhage, there is no single symptom which may not be present. 
A difficulty also results from the fact that in many instances gastralgia is 
one of the symptoms of nervous dyspepsia, and may exist with marked 
emaciation. 

The following points are of value in discriminating between these two 
conditions: 

(a) In ulcer the pain is more definitely connected with taking food, 
though this is not always the case, as in the duodenal form the gastralgic 
all neks may occur at night when the stomach is empty. Eelief of pain 
after eating is certainly less common in ulcer than in gastralgia, though it 
is ;i very uncertain feature, and in certain cases the pain in ulcer is always 
relieved by taking food. 

(&) In nicer dyspeptic symptoms are almost invariably present in the 
intervals between the attacks, and even when pain is absent there is slight 
distress. 

(c) Local sensitiveness over a particular spot in the epigastrium is sug- 
gest ivc of ulcer. External pressure usually aggravates the pain in ulcer, 
and often relieves it in gastralgia. This is, however, a very uncertain fea- 
ture, as patients writhing with the pains of ulcer may press the abdomen 
over the back of a chair or place a hard pillow under it. 

(d) The general condition and history of the patient often give the 



484 



DISEASES OF THE DIGESTIVE SYSTEM. 



most trustworthy information. The nutrition is impaired more frequent- 
ly in ulcer than in gastralgia. The latter is common in neurasthenia 
with superacidity, and may be completely relieved by burnt magnesia 
or soda. Pain may also be associated in this class of cases with sub- 
acidity. 

(e) On examination of the abdomen, not only is pain on pressure much 
more common in ulcer, but there may also be thickening about the pylorus 
and, in many cases, signs of dilatation of the stomach. 

(/) Superacidity and often supersecretion of the gastric juice exists with 
ulcer. 

The gastric crises which occur in affections of the spinal cord, particu- 
larly in locomotor ataxia, may simulate very closely the gastralgic attacks 
of ulcer, and as they so often exist in the preataxic stage their true nature 
may be overlooked; but the occurrence of lightning pains, the ocular symp- 
toms, and the absence of the knee reflex are indications usually sufficient 
to render the diagnosis clear. 

Can the gastric and duodenal ulcer be distinguished clinically? As 
already stated, they originate in the same way and present the same ana- 
tomical characters. In the great majority of cases they cannot be "sepa- 
rated during life, as the symptoms produced are identical. Bucquoy has 
suggested that the duodenal ulcer can be distinguished by the following 
definite characters: (a) Sudden intestinal haemorrhage in an apparently 
healthy person, which tends to recur and produce a profound ana?mia. 
Haemorrhage from the stomach may precede or accompany the melaena. 
(b) Pain in the right hypochondriac region, coming on two or three hours 
after eating, (c) Gastric crises of extreme violence, during which the 
haemorrhage is more apt to occur. Certainly the occurrence of sudden 
intestinal haemorrhage with gastralgic attacks is extremely suggestive of 
duodenal ulcer. W. W. Johnston has reported an instance in which 
he made the diagnosis on these symptoms, and in one of the Montreal 
cases Palmer Howard suggested correctly the presence of a duodenal 
ulcer on similar grounds. A patient under my care who had, during 
eighteen years, frequent attacks of haematemesis with gastralgia had 
melaena repeatedly without vomiting blood; but as a rule in the at- 
tacks the blood was vomited first, and did not appear in the stools un- 
til later. Occasionally this symptom will be found an important aid 
in diagnosis. The situation of the pain is too uncertain a factor on 
which to lay much stress, and the character of the crises is usually 
identical. 

Gall-stone colic may occasionally simulate the pains of gastric ulcer. 
The sudden onset and as sudden termination, the swelling and tenderness 
of the liver, the enlargement of the gall-bladder, if present, and the occur- 
rence of jaundice are points to be considered. The experience of surgeons 
has taught us that a number of cases in which the pains were regarded as 
gastralgia have in reality been due to gall-stones, with which, as is now well 
known, jaundice is not necessarily connected. 

Treatment. — Post-mortem observations show that a very large num- 
ber of ulcers heal completely, but the process is slow and tedious, often 



THE PEPTIC ULCER— GASTRIC AND DUODENAL. 



485 



requiring months, or, in severe cases, years. The following are the im- 
portant points in treatment: 

(a) Absolute rest in bed. 

(b) A carefully and systematically regulated diet. While theoretically 
it is better to give the stomach complete rest by rectal feeding, yet in prac- 
tice this strict limitation is not found satisfactory. The food should be 
bland, easily digested, and given at stated intervals. The following dietary 
will be found useful: At 8 a. m. give 200 cc. of Leube's beef solution; at 
12 M., 300 cc. of milk gruel or peptonized milk. The gruel should be made 
with ordinary flour or arrowroot, and is mixed with an equal quantity of 
milk. If necessary it may be peptonized. Buttermilk is very well borne 
by these patients. At 4 p. m. the beef solution again, and at 8 p. m. the 
milk gruel or the buttermilk. 

The stomach in some cases is so irritable that the smallest amount of 
food is not well borne. In such cases lavage may be practised, if necessary, 
every morning, with mildly alkaline water, after which the beef solution 
is given and the feeding supplemented by the rectal injections. Ill effects 
rarely follow the careful use of the stomach tube in gastric ulcer. There 
are some cases which do well from the outset on a milk diet, given at regu- 
lar intervals, 3 or 4 ounces every two hours. When milk is not well borne 
egg albumen may be substituted, or the whites of eight eggs may be alter- 
nated with Leube's beef solution. At the end of a month, if the condition 
has improved, the patient may be allowed scraped beef or young chicken, 
perfectly fresh sweet-bread, and farinaceous puddings made with milk and 
eggs. Local applications, such as warm fomentations, over the abdomen 
are very useful. The patient should be told that the treatment will take 
at least three months, and for the greater portion of the time he should 
be in bed. 

(c) Medicinal measures are of very litle value in gastric ulcer, and the 
remedies employed do not probably benefit the ulcer, but the gastric ca- 
tarrh. The Carlsbad salts are warmly recommended by von Ziemssen. The 
artificial preparation (sulphate of sodium, 50; bicarbonate of sodium, 6; 
•chloride of sodium, 3) may be substituted, of which a teaspoonful is taken 
every morning. Bismuth, in doses of 30 to 60 grains three times a day, 
and nitrate of silver may be given, but they influence the associated con- 
ditions rather than the ulcer. 

The pain, if severe, requires opium. Unless the gastralgia is intense 
morphia should not be given hypodermically, as there is a very serious 
danger in these cases of establishing the morphia habit. Doses of an 
eighth of a grain, with the bicarbonate of soda and bismuth, will allay the 
mild attacks, but the very severe ones require the hypodermic injection of 
a qunrter or often half a grain. Antipyrin and antifebrin may be tried, 
but, as a rule, are quite ineffectual. In the milder attacks Hoffman's ano- 
dyne, or 20 or 30 drops of chloroform, or the spirits of camphor will give 
relief. Counter-irritation over the stomach with mustard or cantharides is 
•often useful. 

When the stomach is intractable, the patient should be fed per rectum. 
He will sometimes retain food which is passed into the stomach through the 



486 



DISEASES OF THE DIGESTIVE SYSTEM. 



tube, and Leube's beef solution or milk may be given in this way. Cracked 
ice, chloroform, oxalate of cerium, bismuth, hydrocyanic acid, and ingluvin 
may be tried. When haemorrhage occurs the patient should be put under 
the influence of opium as rapidly as possible. No attempt should be made 
to check the haemorrhage by administering medicines by the mouth; as 
the profuse bleeding is always from an eroded artery, frequently from 
one of considerable size, it is doubtful if acetate of lead, tannic and gallic 
acids, and the usual remedies have the slightest influence. The essential 
point is to give rest, which is best obtained by opium. Ergotin may be 
administered hypodermically in two-grain doses. Nothing should be 
given by the mouth except small quantities of ice. In profuse bleeding 
a ligature may be applied around a leg, or a leg and arm. Not infrequently 
the loss of blood is so great that the patient faints. A fatal result is not, 
however, very common from haemorrhage. Transfusion may be necessary, 
or, still better, the subcutaneous infusion of saline solution. 

The patients usually recover rapidly from the haemorrhage and require 
iron in full doses, which may, if necessary, be given hypodermically. 

Surgical interference in ulcer of the stomach is indicated: (a) When 
perforation has taken place. The statistics collected by Eodman and by 
Eobson indicate how successful th^s operation has become, (b) In very in- 
tractable cases which have resisted all treatment, and which are accom- 
panied by attacks of very severe pain and recurring, almost fatal haemor- 
rhage, the ulcer may be excised, (c) For haematemesis. A number of cases 
have now been successfully operated upon for the recurring bleeding. The 
surgeon must bear in mind that the very severe, profuse haemorrhage does 
not always come from the large round ulcers, but, as Dieulaf oy has recently 
pointed out, from quite small erosions. In a case of this kind the operation 
was performed successfully. Eobson (Lancet, 1901, i) and Eodman (Jr. 
Am. Med. Assn., vol. i, 1900) have dealt fully with the surgical aspects 
of the subject. (For discussion on the Statistics of Ulcer see Bramwell, 
Lancet, i, 1901.) 

V. CANCER OF THE STOMACH. 

Etiology. — Incidence. — In an analysis of 30,000 cases of cancer, W. 
H. Welch found the stomach involved in 21.4 per cent, this organ thus 
standing next to the uterus in order of frequency. Among 8,464 cases ad- 
mitted to my wards, there were 150 cases of cancer of the stomach. There 
were 39 cases among the first 1,000 autopsies in the post-mortem room of 
the Johns Hopkins Hospital. The disease is more common in some coun- 
tries. Figures indicate that cancer of the stomach, as of other organs, is 
increasing in frequency. 

Sex. — T. McCrae has analyzed 150 cases from my wards and found that 
there were 126 males and 24 females. Welch gives the ratio as 5 to 4. 

Age. — Of our 150 cases the ages were as follows: Between twenty and 
thirty, 6; from thirty to forty, 17; forty to fifty, 38; fifty to sixty, 49; 
sixty to seventy, 36; seventy to eighty, 4. Fifty-eight per cent occurred 
between the ages of forty and sixty. Of the 6 cases occurring under the 



CANCER OF THE STOMACH. 



487 



thirtieth year, the youngest was twenty-two. Of the large number of cases 
analyzed by Welch, three fourths occurred between the fortieth and seven- 
tieth years. Congenital cancer of the stomach has been described, and 
cases have been met with in children. 

Race. — Among our 150 cases, 131 were white; 19 were negroes. 

Heredity. — Of the 150 cases in only 11 was there a positive history of 
cancer in the family. In some families, as the Bonapartes, the disease seems 
to prevail. In our series a very much larger number — 38 — -had a family 
history of tuberculosis. 

Previous Diseases, Habits, etc. — A history of dyspepsia was present in 
only 33 cases; of these, 17 had had attacks at intervals, 11 had had chronic 
stomach trouble, and 5 had had dyspepsia for one or two years before the 
symptoms of cancer developed. Napoleon, discussing this interesting point 
with his physician Autommarchi, said that he had always had a stomach 
of iron and felt no inconvenience until the onset of what proved to be 
his fatal illness. 

Alcohol. — Seventy-seven of our patients had used it regularly, 65 of 
these moderately (?), 8 excessively. Trauma. — Only one case gave a posi- 
tive history. In a recent case the cancer developed rapidly after a blow on 
the stomach, and the patient lost sixty pounds in weight in three months. 
Gastric Ulcer. — Four cases gave a history pointing to ulcer, but there was 
no instance of ulcus carcinomatosum among the autopsies. • 

Mental worry and strain were given occasionally as causes of the illness. 

Morbid Anatomy. — The most common varieties of gastric cancer 
are the cylindrical-celled adeno-carcinoma and the encephaloid or medul- 
lary carcinoma; next in frequency is scirrhous, and then colloid cancer. 
With reference to the situation of the tumor, Welch analyzed 1,300 cases, 
in which the distribution was as follows: Pyloric region, 791; lesser curva- 
ture, 148; cardia, 104; posterior wall, 68; the whole or greater part of the 
stomach, 61; multiple tumors, 45; greater curvature, 34; anterior wall, 30; 
fundus, 19. 

The medullary cancer occurs in soft masses, which involve all the coats 
of the stomach and usually ulcerate early. The tumor may form villous 
projections or cauliflower-like outgrowths. It is soft, grayish white in 
color, and contains much blood. Microscopically it shows a scanty stroma, 
enclosing alveoli which contain irregular polyhedral and cylindrical cells. 
The cylindrical-celled epithelioma may also form large irregular masses, 
but the consistence is usually firmer, particularly at the edges of the can- 
cerous ulcers. Microscopically the section shows elongated tubular spaces 
filled with columnar epithelium, and the intervening stroma 'is abundant. 
Cysts are not uncommon in this form. The scirrhous variety is character- 
ized by great hardness, due to the abundance of the stroma and the limited 
amount of alveolar structures. It is seen most frequently at the pylorus, 
where it is a common cause of stenosis. It may be combined with the 
medullary form. It may be diffuse, involving all parts of the organ, and 
leading to a conditio!] which cannot be recognized macroscopically from 
cirrhosis. This form has also been seen in the stomach secondary to cancer 
of the ovaries. The colloid cancer is peculiar in its widespread invasion 



488 



DISEASES OF THE DIGESTIVE SYSTEM. 



of all the coats. It also spreads with greater frequency to the neighboring 
parts, and it occasionally causes extensive secondary growths of the same 
nature in other organs. The appearance on section is very distinctive, 
and even with the naked eye large alveoli can be seen filled with the trans- 
lucent colloid material. The term alveolar cancer is often applied to this 
form. Ulceration is not constantly present, and there are instances in 
which, with most extensive disease, digestion has been but slightly dis- 
turbed. There is a specimen in the Warren Museum, at the Harvard Medi- 
cal School, of the most widespread colloid cancer, in which the stomach 
contained after death large pieces of undigested beef -steak. 

Secondary Cancer of the Stomach. — Of 37 cases collected by Welch, 17 
were secondary to cancer of the breast. Among the first 1,000 autopsies 
at the Johns Hopkins Hospital there were 3 cases of secondary cancer. 

Changes in the Stomach. — Cancer at the cardia is usually associated with 
wasting of the organ and reduction in its size. The oesophagus above the 
obstruction may be greatly dilated. On the other hand, annular cancer 
at the p} T lorus causes stenosis with great dilatation of the organ. In a few 
rare instances the pylorus has been extremely narrowed without any in- 
crease in the size of the stomach. In diffuse scirrhous cancer the stomach 
may be very greatly thickened and contracted. It may be displaced or 
altered in shape by the weight of the tumor, particularly in cancer of the 
pylorus; in such cases it has been found in every region of the abdomen, and 
even in the true pelvis. The mobility of the tumors is at times extraordi- 
nary and very deceptive, and they may be pushed into the right hypochon- 
drium or into the splenic region, entirely beneath the ribs. Adhesions very 
frequently occur, particularly to the colon, the liver, and the anterior 
abdominal wall. 

Secondary cancerous growths in other organs are very frequent, as 
shown by the following analysis by Welch of 1,574 cases: Metastasis oc- 
curred in the lymphatic glands in 551; in the liver in 475; in the peri- 
tonaeum, omentum, and intestine in 357; in the pancreas in 122; in the 
pleura and lung in 98; in the spleen in 26; in the brain and meninges in 
'9; in other parts in 92. The lymph-glands affected are usually those of 
the abdomen, but the cervical and inguinal glands are not infrequently 
attacked, and give an important clue in diagnosis. Secondary metastatic 
growths occur subcutaneously, either at the navel or beneath the skin in 
the vicinity, and are of great value in diagnosis. In one instance a patient 
with jaundice, which had developed somewhat suddenly and was believed to 
b>e catarrhal, presented no signs of enlargement of the liver or tumor of the 
•stomach, but a nodular body appeared at the navel, which on removal 
proved to be typical scirrhus. A second case in the ward at the same 
time, with an obscure doubtful tumor in the left hypochondrium, developed 
a painful nodular subcutaneous growth midway between the navel and the 
left margin of the ribs. 

Perforation.- — In the extensive ulceration which occurs perforation of 
the stomach is not uncommon. It occurred into the peritonaeum in 17 of 
the 507 cases of cancer of the stomach collected by Brinton. In our series 
perforation is recorded in 4 cases. When adhesions form, the most extensive 



CANCER OF THE STOMACH. 



489 



destruction of the walls may take place without perforation into the peri- 
toneal cavity. In one instance which came under my observation a large 
portion of the left lobe of the liver lay within the stomach. Occasionally 
a gastro-cutaneous fistula is established. Perforation may occur into the 
colon, the small bowel, the pleura, the lung, or into the pericardium. 

Symptoms. — Latent Carcinoma. — The cases are not very infrequent. 
There may be no symptoms pointing to the stomach, and the tumor may 
he discovered accidentally after death. In a second group the symptoms' 
of carcinoma are present, not of the stomach, but of the liver or some other 
•organ, or there are subcutaneous nodules, or, as in one of our cases, second- 
ary masses on the ribs and vertebrae. In a third group, seen particularly in 
elderly persons in institutions, there is gradual asthenia, without nausea, 
vomiting, or other local symptoms. 

Features of Onset. — Of the 150 cases in our series, 48 complained of 
pain, 44 of dyspepsia, 21 of vomiting, 13 of loss in weight, 3 of difficulty 
in swallowing, 1 of tumor. In 7 the features of onset suggested pernicious 
anaemia. In 37 cases there was a history of sudden onset. 

General Symptoms. — Loss of Weight. — Progressive emaciation is one 
of the most constant features of the disease. In 79 of our cases in which 
■exact figures were taken: To 30 pounds, 32 cases; 30 to 50 pounds, 36 cases; 
50 to 60 pounds, 5 cases; 60 to 70 pounds, 4; over 70 pounds, 1; 100 
pounds, a case of cancer at the cardiac end with obstruction to swallowing. 
The loss in weight is not always progressive. We see increase in weight 
under three conditions: (a) Proper dieting, with treatment of the associated 
•catarrh of the stomach; (b) in cases of cancer of the pylorus after relief of the 
dilatation of the organ by lavage, etc.; (c) after a profound mental impres- 
sion. I have known a gain of ten pounds to follow the visit of an optimistic 
•consultant. In Keen and D. D. Stewart's case there was a gain of seventy 
pounds after an exploratory operation! 

Loss in strength is usually proportionate to the loss in weight. One sees 
sometimes remarkable vigor almost to the close, but this is exceptional. 

Ancemia is present in a large proportion of all cases, and with the emaci- 
ation gives the picture of cachexia. There is often a yellow or lemon tint 
of the skin. In 59 cases careful blood-counts were made, in 3 the red cor- 
puscles were above 6,000,000 per cubic millimetre. This occurs in the 
concentrated condition of the blood in certain cases of cancer of the pylorus 
with dilatation of the stomach. The average count in the 59 cases was 
3,712,186 per cubic millimetre. In only 8 cases was the count below 2,000,- 
•000, and in none below 1,000,000. The average of the haemoglobin was 
44.9 per cent. In only 9 was it below 30 per cent. In 62 cases in which 
the leucocytes were counted there were only 18 cases in which they were 
above 12,000 per cubic millimetre; in only 3 cases were they above 20,000. 
As mentioned, there were 7 cases in which the features of onset suggested 
a primary anaemia. To this question we shall return under diagnosis. 

Among other general symptoms may be mentioned fever. Of onr 150 
cases, 74 showed some fever. In only 13 of these was the temperature 
above 101°. In 2 it was above 103°. Fifteen presented fairly constaiil 
elevation of temperature. Eight presented sudden rises. Two cases had 



490 



DISEASES OF THE DIGESTIVE SYSTEM. 



chill, with elevation to 103° and 104°. Chills may be associated with sup- 
puration at the base of the cancer. 

Urine. — There may be no changes throughout; in 65 of our cases there 
were no alterations, in 36 albumin was found, and in 34 albumin with tube- 
casts. Glycosuria, peptonuria, and acetonuria have been described. Indican 
is common. 

(Edema. — Swelling of the ankles is of frequent occurrence toward the 
close. In some cases there is even early a general anasarca, usually in com- 
bination with extreme anamiia. The cancer is usually overlooked. 

The bowels are often constipated. In only 12 cases in our series was 
diarrhoea present. In 2 cases blood was passed per rectum. There are no 
special cardiac symptoms; the pulse becomes progressively weaker. Throm- 
bosis of one femoral vein may occur or, as in one of our cases, widespread 
thrombosis in the superficial veins of the body. 

Symptoms on the part of the nervous system are rare; consciousness 
is often retained to the end. Coma may develop — viz., similar to that seen 
in diabetes, and is believed to be due to an acid intoxication. 

Functional Disturbances. — Anorexia, loss of desire for food, is a fre- 
quent and valuable symptom, more constant perhaps than any other. 
Nausea is a striking feature in many cases; there is often a sudden re- 
pulsion at the sight of food. In exceptional cases the appetite is retained 
throughout. 

Vomiting may come on early, or only after the dyspepsia has persisted 
for some time. It occurred in 128 cases in our series. At first it is at long 
intervals, but subsequently it is more frequent, and may recur several times 
in the day. There are cases in which it comes on in paroxysms and then 
subsides; in other cases, it sets in early, persists with great violence, and 
may cause a fatal termination within a few weeks. Vomiting is more fre- 
quent when the cancer involves the orifices, particularly the pylorus, in 
which case it is usually delayed for an hour or more after taking the food. 
TVhen the cardiac orifice is involved it may follow at a shorter interval. 
Extensive disease of the fundus or of the anterior or posterior wall may 
be present without the occurrence of vomiting. The food is sometimes very 
little changed, even after it has remained in the stomach for twenty-four 
hours. 

Hemorrhage occurred in 36 of our 150 cases; in 32 the blood was dark 
and altered, in 3 it was bright red. In 2 cases vomiting of blood was the 
first symptom. The bleeding is rarely profuse; more commonly there is 
slight oozing, and the blood is mixed with, or altered by the secretions, 
and, when vomited, the material is dark brown or black, the so-called 
" coffee-ground " vomit. The blood can be recognized by the microscope as 
shadows of the red blood-corpuscles and irregular masses of altered blood 
pigment. In cases of doubt the spectroscope may be employed or hgemin 
crystals obtained. 

Pain, an early and important symptom, was present in 130 of our cases. 
It is very variable in situation, and while most common in the epigastrium, 
it may be referred to the shoulders, the back, or the loins. The pain is 
described as dragging, burning, or gnawing in character, and very rarely 



CANCER OF THE STOMACH. 



491 



occurs in severe paroxysms of gastralgia, as in gastric nicer. As a rule, the 
pain is aggravated by taking food. There is usually marked tenderness on 
pressure in the epigastric region. The areas of skin tenderness are referred, 
as Head has shown, to the region' between the nipple and the umbilicus 
in front and behind from the fifth to the twelfth thoracic spine. 

Examination of the Stomach Contents. — The vomitus in suspected cases 
should be carefully studied, particularly as to quantity and character of 
ingredients. Large amounts brought up at intervals of a few days, with 
the appearances already described, are characteristic of dilatation of the 
stomach. Some of the material should be spread in a large glass plate and 
any. suspicious portions picked out for examination. Bacteria in large num- 
bers occur, one, the Oppler-Boas bacillus — an unusually long non-mobile 
form — is supposed to be of diagnostic value, and to be largely responsible 
for the formation of lactic acid. The yeast fungus is very commonly found, 
sarcinse less frequently than in dilatation from stricture. Blood is a most 
important ingredient; the persistent presence microscopically of red cor- 
puscles in the early morning washings is always very suspicious. Later, 
when coffee-ground vomiting takes place, the macroscopic evidence is suf- 
ficient. In cases of doubt the spectroscope may be used or the test made 
for hamiin crystals. Fragments of the new growth may be vomited or may 
appear in the washings. Positive evidence of cancer may be obtained from 
them. 

Examination of tlie Test Breakfast. — The Ewald test meal, consisting 
of a slice of stale bread and a large cup of weak tea without cream or sugar, 
is given at 7 a. m. and withdrawn at 8 a. m. The Boas test meal, consisting 
of a gruel made of a tablespoonful of oatmeal flour in a litre of water, is 
used in the estimation of lactic acid. As an outcome of the enormous 
number of observations made of late years, it may be said that free HC1 
is absent in a large proportion of all cases of cancer of the stomach. Of 
94 cases in which the contents were examined in 84 free HC1 was absent. 
In 5 undoubted cases the reaction was good; in 2 of these the history sug- 
gested previous ulcer. HC1 may be absent in chronic gastritis and in 
atrophy of the gastric mucosa. (For a good discussion of hydrochloric-acid 
determinations see J. S. Thatcher, Presbyterian Hospital Eeports, vol. iii.) 
The presence of lactic acid after Boas' test meal is regarded as a valuable 
sign. It is rarely present in chronic catarrhal conditions, but, as Stockton 
and Jones conclude, it is by no means positive evidence of carcinoma ven- 
triculi. 

Physical Examination. — (a) Inspection. — After a preliminary sur- 
vey, embracing the facies, state of nutrition, etc., particular direction is 
given to the abdomen. An all-important matter is to have the patient in 
a good light. Fulness in the epigastric region, inequality in the infracostal 
grooves, the existence of peristalsis, a wide area of aortic pulsation, the 
presence of subcutaneous nodules or small masses about the navel, and, 
lastly, a well-defined tumor mass — these, together or singly, may be seen 
on careful inspection. I cannot emphasize too strongly the value of this 
method of examination. Tn 02 of the 150 cases a positive tumor could be 
seen. In 52 the tumor descended with inspiration; in 30 peristalsis was 



492 



DISEASES OF THE DIGESTIVE SYSTEM. 



visible; in 3 cases movements were visible in the tumor itself. In 10 cases 
with, visible peristalsis no tumor was seen, but could be felt on palpation. 
Inflation with carbonic-acid gas may be tried, except when haemorrhage 
has been profuse or the cancer is very extensive. The dilatation often ren- 
ders evident the peristalsis or may bring a tumor into view. The presence 
of subcutaneous and umbilical nodules is sometimes a very great help. They 
were found in 5 of our series. Palpation. — In 115 cases a tumor could be 
felt; in 48 in the epigastric region, in 25 in the umbilical, in 18 in the left 
hypochondriac, in 17 in the right hypochondriac region, while in 7 cases a 
mass descended in deep inspiration from beneath the left costal margin. 
These figures illustrate in how large a proportion of the cases the tumor is in 
evidence. In rare cases examination in the knee-elbow position is of value. 
Mobility in gastric tumor is a point of much importance. First, the change 
with respiration, already referred to; a mass may descend 3 or 4 inches 
in deep inspiration; secondly, the communicated pulsation from the aorta, 
which is often in its extent suggestive; thirdly, the intrinsic movements 
in the hypertrophied muscularis in the neighborhood of the cancer. This 
may give a remarkable character to the mass, causing it to appear and disap- 
pear, lifting the abdominal wall in the epigastric region; and, fourthly, 
mechanical movements, with inflation, with change of posture, or com- 
municated with the hand. Tumors of the pylorus are the most movable, 
and in extreme cases can be displaced to either hypochondrium or pushed 
far down below the navel (see illustrative cases in my Lectures on the Diag- 
nosis of Abdominal Tumors). Pain on palpation is common; the mass is 
usually hard, sometimes nodular. Gas can at times be felt gurgling through 
the tumor at the pyloric region. 

Percussion gives less important indications — the note over a tumor is 
rarely flat, more often a flat tympany. Auscultation may reveal the 
gurgling through the pylorus; sometimes a systolic bruit is transmitted 
from the aorta, and when a local peritonitis exists a friction may be heard. 

Complications. — Secondary growths are common. In 44 autopsies in 
our series there were metastases in 38; in 29 the lymph-glands were in- 
volved; in 23 the liver, in 11 the peritonaeum, in 8 the pancreas, in 8 the 
bowel, in 4 the lung, in 3 the pleura, in 4 the kidneys, and in 2 the spleen. 
In 8 no deposits were found. 

Perforation may lead to peritonitis, but in 3 of our 4 cases there was 
no general involvement. Cancerous ascites is not very uncommon. Dock 
has called attention to the value of the examination of the fluid in such 
cases as a help to diagnosis. The cells show mitoses and are very charac- 
teristic. Secondary cancer of the liver is very common; the enlargement 
may be very great, and such cases are not infrequently mistaken for 
primary cancer of the organ. Involvement of the lymph-glands may give 
valuable indications. There may be early enlargement of a gland at the 
posterior border of the left sterno-cleido-mastoid muscle; later adjacent 
glands may become affected. This occurs also in uterine cancer. Accord- 
ing to Williams, Trosier was the first to describe this condition, which must 
not be confounded with the pseudo-lipome sus-claviculaire of Verneuil. 

A very remarkable picture is presented when the cancer slouglis or be- 



CANCER OF THE STOMACH. 



493 



comes gangrenous; the vomitus has a foul odor, often of a penetrating na- 
ture, to be perceived throughout the room. In cases in which the ulcer 
perforates the colon, the vomiting may be faecal. I have, however, met with 
the faecal odor in a case with incessant vomiting; there was no perforation of 
the colon at autopsy. 

Course. — While usually chronic and lasting from a year to eighteen 
months, acute cancer of the stomach is by no means infrequent. Of the 
69 cases in which we could determine accurately the duration, 15 lasted 
under three months, 16 from three to six months, 14 from six to twelve 
months — a total of 45 under one year. Four cases lasted for two years or 
over. One case lived for at least two years and a half. 

Diagnosis. — In 115 of our 150 cases a tumor existed, and with this 
the recognition is rarely in doubt. Practically the chief difficulty is in 
those cases which present gastric symptoms or anaemia, or both, without 
the presence of tumor. In the one a chronic gastritis is suspected; in the 
other a primary anaemia. In chronic gastritis the history of long-standing 
dyspepsia, the absence of cachexia, the absence of lactic acid in the test 
meal, and the less striking blood changes are the important points for con- 
sideration. The cases with grave anaemia without tumor offer the greatest 
difficulty. The blood-count is rarely so low as in pernicious anaemia, a 
point on which F. P. Henry has laid special stress. In only 8 of our 59 
cases with careful blood examination was the number below 2,000,000 
per cubic millimetre. The lower color index, as in secondary anaemia, the 
absence of megaloblasts, and a leucocytosis speak for cancer. Some lay 
stress on the differential count of the leucocytes, but there is not evidence 
enough to enable us to speak positively on this point. The digestion leuco- 
cytosis might be a help in some cases. The chemical findings are of greater 
value. The constant presence of lactic acid and the absence of HC1 have 
in several of our cases suggested the diagnosis of cancer, which has been 
verified later on by the development of a tumor. 

From ulcer of the stomach malignant disease is, as a rule, readily recog- 
nized. The ulcus carcinomatosis usually presents a well-marked history of 
ulcer for years. Hemmeter has given a good account of this rare condi- 
tion in his recent work on the stomach. The greatest difficulty is offered 
when there is ulcer with tumor due to cicatricial contraction about the 
pylorus. In 3 such cases we mistook the mass for cancer, and even at 
operation it may (as in one of them) be impossible to say whether a neo- 
plasm is present. The persistent hyperchlorhydria is the most important 
single feature of ulcer, and, taken with the gastralgic attacks and the haem- 
orrhages, rarely leave doubt as to the condition. 

Nowadays, when exploratory laparotomy may be advised with such 
safety, the surgeon often makes the diagnosis. 

The practitioner should recognize the fact that there are cases of cancer 
of the stomach in which a positive diagnosis cannot be reached for weeks 
or months by any known means at our command. 

Treatment. — The disease is incurable and palliative measures are 
alone indicated. The diet should consist of readily digested substances of 
all sorts. Many patients do best on milk alone. Washing out of the 



494 



DISEASES OF THE DIGESTIVE SYSTEM. 



stomach, which may be done with a soft tube without any risk, is particu- 
larly advantageous when there is obstruction at the pylorus, and is by far 
the most satisfactory means of combating the vomiting. The excessive 
fermentation is also best treated by lavage. When the pain becomes se- 
vere, particularly if it disturbs the rest at night, morphia must be given. 
One eighth of a grain, combined with carbonate of soda (gr. v), bismuth 
(gr. v-x), usually gives prompt relief, and the dose does not always require 
to be increased. Creasote (nij-ij) and carbolic acid are very useful. The 
bleeding in gastric cancer is rarely amenable to treatment. Operative 
measures have been advised and practised, and in exceptional instances 
there are cases in which the limited cancer or even the entire organ has 
been resected. 

Other Forms of Tumor. — Non-cancerous tumors of the stomach rarely 
cause inconvenience. Polypi (polyadenomata) are common and they may 
be numerous; as many as 150 have been reported in one case. There is a 
form in which the adenoma exists as an extensive area slightly raised above 
the level of the mucosa — polyadenome en nappe of the French. H. B. An- 
derson has described a case of remarkable multiple cysts in the walls of the 
stomach and small intestine. Sarcomata are very rare. Fibromata and 
lipomata have been described. 

Foreign oodies occasionally produce remarkable tumors of the stomach. 
The most extraordinary is the hair tumor, of which there are 16 cases in the 
literature. The cases occur in hysterical women who have been in the habit 
of eating their own hair. A specimen in the medical museum of McG-ill 
TTniversity is in two sections, which form an exact mould of the stomach. 
The tumors are large, very puzzling, and are usually mistaken for cancer. 
Of 7 cases operated upon, 6 recovered; in 9 cases the condition was found 
post mortem (Schulten). 



VI. HYPERTROPHIC STENOSIS OF THE PYLORUS. 

(a) In Adults. — Any one with a large post-mortem experience has met 
with instances of dilated stomachs in connection with thickening or hyper- 
trophy of the pylorus, sometimes forming a tumor large enough to be felt, 
and suggesting the presence of a new growth. Microscopically, however, 
the condition is found to be very largely hypertrophy of the muscularis and 
submucosa of the pylorus. It was well described by the older writers. The 
symptoms are those of dilatation of the stomach. The condition has been 
fully discussed recently by Boas (Archiv fur Yerdauungskrankheiten, Bd. 4, 
I), who reports two interesting cases with successful gastroenterostomy. 
The question is whether some of these cases may not really be congenital, 
as there have been instances reported in girls as early as the twelfth and 
sixteenth years. 

(b) Congenital Hypertrophy of the Pylorus. — On this interesting condi- 
tion a closer study has been made since 1897. when John Thomson, of 
Edinburgh, directed attention to it. Eolleston and Crofton-Aikens have 
collected 45 cases, most of which were under four months old. 



HEMORRHAGE FROM THE STOMACH. 



495 



It has been regarded as a congenital gastric spasm (Thomson), but 
there is also hypertrophy of the pylorus. In an infant under four months 
obstinate vomiting, wasting, constipation, and the presence of a tumor 
suggested the diagnosis. A few cases have recovered; six have been oper- 
ated on, in one (Loreta's operation) recovery followed. 



VII. HEMORRHAGE FROM THE STOMACH (Hcematemesis). 

Etiology. — Gastrorrhagia, as this symptom is called, may result from 
many conditions, local or general. 1. In local disease: (a) cancer; (b) ulcer; 
(c) disease of the blood-vessels, such as miliary aneurisms and occasionally 
varicose veins; (d) acute congestion, as in gastritis, and possibly in vicari- 
ous haemorrhage; (e) following operations in the abdomen, particularly when 
the omentum is Avounded, erosions of the gastric mucosa may occur, from 
which haemorrhage takes place. 

2. Passive congestion due to obstruction in the portal system. This 
may be either (a) hepatic, as in cirrhosis of the liver, thrombosis of the 
portal vein, or pressure upon the portal vein by tumor, and secondarily in 
•cases of chronic disease of the heart and lungs; (b) splenic. Gastrorrhagia 
is by no means an uncommon symptom in enlarged spleen, and is ex- 
plained by the intimate relations which exist between the vasa brevia and 
the splenic circulation. 

3. Toxic: (a) The poisons of the specific fevers, small-pox, measles, 
yellow fever; (b) poisons of unknown origin, as in acute yellow atrophy 
and in purpura; (c) phosphorus. 

4. Traumatism: (a) Mechanical injuries, such as blows and wounds, 
and occasionally by the stomach-tube; (b) the result of severe corrosive 
poisons. 

5. Certain constitutional diseases: (a) Haemophilia; (b) profound anae- 
mias, whether idiopathic or due to splenic enlargements or to malaria; (c) 
cholaemia. 

G. In certain nervous affections, particularly hysteria, and occasionally 
in progressive paralysis of the insane and epilepsy. 

7. The blood may not always come primarily from the stomach. Thus 
it may belong to the nose or the pharynx. In haemoptysis some of the 
blood may find its way into the stomach. Again, in bleeding from the 
oesophagus Mood may trickle into the stomach, from which it is ejected. 
This occur- in the case of rupture of aneurism and of the oesophageal 
varices. A child may draw blood with the milk from the mother's breast 
even in considerable quantities and then vomit it. 

8. Miscellaneous causes: Aneurism of the aorta or of its branches may 
rupture into I lie stomach. There are instances in which a patient has 
vomited blood once without ever having a recurrence or without develop- 
ing symptoms pointing to disease of the stomach. 

In new-born infants haematemesis may occur alone or in connection 
with bleeding from other mucous membranes. 
31 ' 



496 



DISEASES OP THE DIGESTIVE SYSTEM. 



In medical practice, haemorrhage from the stomach occurs most fre- 
quently in connection with cirrhosis of the liver and ulcer of the stomach. 
It is more frequent in women than in men, owing to the greater prevalence 
of round ulcer in the former. 

Morbid Anatomy. — When death has occurred from the haemate- 
mesis there are signs of intense anaemia. The condition of the stomach 
varies extremely. The lesion is evident in cancer and in ulcer of the stom- 
ach. It is to be borne in mind that fatal haemorrhage may come from a 
small miliary aneurism communicating with the surface by a pin-hole per- 
foration, or the bleeding may be due to the rupture of a submucous vein 
and the erosion in the mucosa may be small and readily overlooked. It 
may require a careful and prolonged search to avoid overlooking such 
lesions. In the large group associated with portal obstruction, whether 
due to hepatic or splenic disease, the mucosa is usually pale, smooth, and 
shows no trace of any lesion. In cirrhosis, fatal by haemorrhage, one may 
sometimes search in vain for any focal lesion to account for the gastror- 
rhagia, and we must conclude that it is possible for even the most profuse 
bleeding to occur by diapedesis. The stomach may be distended with blood 
and yet the source of the haemorrhage be not apparent either in the stomach 
or in the portal system. In such cases the oesophagus should be examined, 
as the bleeding may come from that source. In toxic cases there are in- 
variably haemorrhages in the mucous membrane itself. 

Symptoms. — In rare instances fatal syncope may occur without any 
vomiting. In a case of the kind, in which the woman had fallen over and 
died in a few minutes, the stomach contained between three and four 
pounds of blood. The sudden profuse bleedings rapidly lead to profound 
anaemia. When due to ulcer or cirrhosis the bleeding usually recurs for 
several days. Fatal haemorrhage from the stomach is met with in ulcer, 
cirrhosis, enlargement of the spleen, and in instances in which an aneurism 
ruptures into the stomach or oesophagus. Gastrorrhagia may occur in 
splenic anaemia or in leukaemia before the condition has aroused the at- 
tention of friends or physician. 

The vomited blood may be fluid or clotted; it is usually dark in color, 
but in the basin the outer part rapidly becomes red from the action of the 
air. The longer blood remains in the stomach the more altered is it when 
ejected. 

The amount of blood lost is very variable, and in the course of a day 
the patient may bring up three or four pounds, or even more. In a case 
under the care of George Eoss, in the Montreal General Hospital, the pa- 
tient lost during seven days ten pounds, by measurement, of blood. The 
usual symptoms of anaemia develop rapidly, and there may be slight fever, 
and subsequently oedema may occur. Syncope, convulsions, and occasion- 
ally hemiplegia occur after very profuse haemorrhage. An interesting cir- 
cumstance connected with gastro-intestinal haemorrhage is the development 
of amaurosis, the mode of production of which is still under discussion. 

Diagnosis. — In a majority of instances there is no question as to 
the origin of the blood. Occasionally it is difficult, particularly if the case 
has not been seen during the attack. Examination of the vomit readily 



NEUROSES OF THE STOMACH. 



497 



determines whether blood is present or not. The materials vomited may 
be stained by wine, the juice of strawberries, raspberries, or cranberries, 
which give a color very closely resembling that of fresh blood, while iron 
and bismuth and bile may produce the blackish color of altered blood. In 
such cases the microscope will show clearly the presence of the shadowy 
outlines of the red blood-corpuscles, and, if necessary, spectroscopic and 
chemical tests may be applied. 

Deception is sometimes practised by hysterical patients, who swallow 
and then vomit blood or colored liquids. With a little care such cases can 
usually be detected. The cases must be excluded in which the blood passes 
from the nose or pharynx, or in which infants swallow it with the milk. 

There is not often difficulty in distinguishing between haemoptysis and 
hsematemesis, though the coughing and the vomiting are not infrequently 
combined. The following are points to be borne in mind in the diagnosis: 

HiEMATEMESIS. HAEMOPTYSIS. 

1. Previous history points to gas- 
tric, hepatic, or splenic disease. 

2. The blood is brought up by 
vomiting, prior to which the patient 
may experience a feeling of giddiness 
or faintness. 

3. The blood is usually clotted, 
mixed with particles of food, and 
has an acid reaction. It may be 
dark, grumous, and fluid. 

4. Subsequent to the attack the 
patient passes tarry stools, and signs 
of disease of the abdominal viscera 
may be detected. 

Prognosis. — Except in the case of rupture of an aneurism or of large 
veins, ha?matemesis rarely proves fatal. In my experience death has fol- 
lowed more frequently in cases of cirrhosis and splenic enlargement than 
in nicer or cancer. In ulcer it is to be remembered that in the chronic 
hemorrhagic form the bleeding may recur for years. The treatment of 
haematemesis is considered under gastric ulcer. 

VIII. NEUROSES OF THE STOMACH (Nervous Dyspepsia). 

The studies of Leube, Ewald, Oser, Rosenbach, and many others have 
shown that serious functional disturbances of the stomach may occur with- 
out any discoverable anatomical basis. The cases are met with most fre- 



1. Cough or signs of some pul- 
monary or cardiac disease precedes, 
in many cases, the haemorrhage. 

2. The blood is coughed up, 
and is usually preceded by a sensa- 
tion of tickling in the throat. If 
vomiting occurs, it follows the 
coughing. 

3. The blood is frothy, bright 
red in color, alkaline in reaction. 
If clotted, rarely in such large co- 
agula, and muco-pus may be mixed 
with it. 

4. The cough persists, physical 
signs of local disease in the chest 
may usually be detected, and the 
sputa may be blood-stained for many 
days. 



498 



DISEASES OF THE DIGESTIVE SYSTEM. 



quently in those who have either inherited a nervous constitution or who 
have gradually, through indiscretions, brought about a condition of nervous 
prostration. Not infrequently, however, the gastric symptoms stand so far 
in the foreground that the general neuropathic character of the patient 
quite escapes notice. Sometimes the gastric manifestations have appar- 
ently a reflex origin depending on organic disturbances in remote parts of 
the body. 

The nervous derangements of the stomach may be divided into motor, 
secretory, and sensory neuroses. These disturbances rarely occur singly; 
they are usually met with in combined forms. The clinical picture result- 
ing from such a complex of gastric neuroses is known as nervous dyspepsia. 
There, as Leube has pointed out, the sensory disturbances usually play the 
more important part. 

The sufferer from nervous dyspepsia presents a varying picture. All 
grades occur, from the emaciated skeleton-like patient with anorexia 
nervosa to the well-nourished, healthy-looking, fresh-complexioned indi- 
vidual whose only complaint is distress and uneasiness after eating. I have 
followed EiegeFs classification as given in his recent exhaustive work on 
the stomach. 

I. Motor Neuroses. — (a) HyperMnesis or Super motility. — An increase in 
the normal motor activity of the stomach results in too early a discharge of 
the ingesta into the intestine. It is more commonly a secondary neurosis 
dependent upon superacidity or supersecretion of the gastric juice; but it 
may occur primarily, possibly from reflex causes. The diagnosis is to be 
reached only by means of the stomach-tube. It gives rise to no charac- 
teristic clinical symptoms. 

(b) Peristaltic Unrest. — This condition, as described by Kussmaul, is 
an extremely common and distressing symptom in neurasthenia. Shortly 
after eating the peristaltic movements of the stomach are increased, and 
borborygmi and gurgling may be heard, even at a distance. The sub- 
jective sensations are most annoying, and it would appear as if in the hyper- 
jesthetic condition of the nervous system the patient felt normal peristalsis, 
just as in these states the usual beating of the heart may be perceptible 
to him. A further analogy is afforded by the fact that emotion increases 
this peristalsis.* It may extend to the intestines, particularly to the duode- 
num, and on palpation over this region the gurgling is most marked. The 
movement may be anti-peristalsis, in which the wave passes from right to 
left, a condition which may also extend to the intestines. There are cases 
on record in which colored enemata or even scybala have been discharged 
from the mouth. 

(c) Nervous Eructations. — In this condition severe attacks of noisy 
eructations, following one another often in rapid succession, occur. When 
violent they last for hours or days. At other times they occur in paroxysms, 
depending often upon mental excitement. They are more commonly ob- 
served in hysterical women and neurasthenics, but also, not infrequently, 
in children. The hysterical nature of the affection is sometimes testified 
to by the occurrence, especially in children, of several instances in one 
household. 



NEUROSES OF THE STOMACH. 499 

The expelled gas in these cases is atmospheric air, which is swallowed 
or aspirated from without. Sometimes the whole process may be clearly 
observed, but in other instances the act of swallowing may be almost or 
quite imperceptible. Bouveret considers the condition due to a spasm of 
the pharynx which causes involuntary swallowing. Oser has suggested that 
the air may enter by aspiration, the stomach acting like an elastic rubber 
bag which tends to fill again after the air is expressed. It is quite possible 
that in some instances the eructations consist of gas which has never actually 
reached the stomach, but is brought up from the oesophagus. 

(d) Nervous Vomiting. — A condition which is not associated with ana- 
tomical changes in the stomach or with any state of the contents, but is due 
to nervous influences acting either directly or indirectly upon the centres 
presiding over the act of vomiting. The patients are, as a rule, women — 
usually brunettes — and the subject of more or less marked hysterical mani- 
festations. A special feature of this form is the absence of the preliminary 
nausea and of the straining efforts of the ordinary act of vomiting. It is 
rather a regurgitation, and without visible effort and without gagging the 
mouth is filled with the contents of the stomach, which are then spat out. 
It comes on, as a rule, after eating, but may occur at irregular intervals. 
In some cases the nutrition is not impaired, a feature which may give a 
clew to the true nature of the disease, as there may be no other hysterical 
manifestation present. As noted by Tuckwell, it may occur in children. 
Xervous vomiting is rarely serious. 

A type of vomiting is that associated with certain diseases of the nerv- 
ous system — particularly locomotor ataxia — forming part of the gastric 
crises. Ley den has reported cases of primary periodic vomiting, which he 
regards as a neurosis. 

(e) Rumination; Merycismus. — In this remarkable and rare condition 
the patients regurgitate and chew the cud like ruminants. It occurs in 
neurasthenic or hysterical persons, epileptics, and idiots. In some patients 
it is hereditary. There is an instance in which a governess taught it to two 
children. The habit may persist for years, and does not necessarily impair 
the health. 

(/) Spasm of the Cardia. — Spasmodic, usually painful contraction of the 
circular muscle fibres at the cardiac orifice may follow the introduction of 
a sound, hasty eating, or the taking of too hot or too cold food. It may 
occur in tetanus and also in hysterical and neurasthenic individuals, espe- 
cially in air sw allowers, in whom, if it be combined with pyloric spasm, it 
may resull in painful gastric distention — ^pneumatosis." Here the spasm 
may be of considerable duration. The condition is rare and practically 
not of much moment. 

({/) Pyloric Spasm. — This is usually a secondary occurrence, following 
superacid ity, supersecretion, ulcer, or the introduction into the stomach 
of irritating substances. The spasm often causes pain in the region of the 
pylorus ami increased gastric peristalsis. In cases where the spasm is com- 
bined with superacid ity and supersecretion marked dilatation with atony 
may follow; it is questionable, however, whether a primary nervous pyloric 
spasm ever gives rise to serious results. T have already referred to John 



500 



DISEASES OF THE DIGESTIVE SYSTEM. 



Thomson's views of pyloric spasm in association with the congenital form 
of hypertrophic stenosis of the pjiorus. 

(h) Atony of the Stomach. — Motor insufficiency of the stomach is gen- 
erally clue to injudicious feeding, to organic disease of the stomach itself, 
or to general wasting processes. In some otherwise normal individuals of 
neurotic temperaments an atony may, however, occur which possibly de- 
serves to be classed among the neuroses. The symptoms are usually those 
of a moderate dilatation, and are often associated with marked sensory dis- 
turbances — feelings of weight and pressure, distention, eructations*, and so 
forth. 

Great care must be taken in the diagnosis to rule out all other possible 
causes. 

(i) Insufficiency or Incontinence of the Pylorus. — This condition was de- 
scribed first by de Sere and later by Ebstein. It may be recognized by the 
rapid passing of gas from the stomach into the bowel on attempts at infla- 
tion of the former, as well as by the presence of bile and intestinal contents 
in the stomach. There are no distinctive clinical symptoms. 

(j) Insufficiency of the Cardia. — This condition is only recognized by 
the occurrence of eructations or in rumination. 

II. Secretory Neuroses. — (a) Hyperacidity ; Superacidity ; Hyper- 
chlorhydria. — Nervous dyspepsia with hyperacidity of the gastric juices. 
The symptoms depend upon the secretion of an abnormally acid gastric juice 
at the time of digestion. This is a common form of dyspepsia in young and 
neurotic individuals. Osswald has pointed out its remarkable frequency 
in chlorotic girls. The symptoms are very variable. They do not, as a rule, 
immediately follow the ingestion of food, but occur one to three hours later, 
at the height of digestion. There is a sense of weight and pressure, some- 
times of burning in the epigastrium, commonly associated with acid eructa- 
tions. If vomiting occurs, the pain is relieved. The patient is usually rela- 
tively well nourished, and the appetite is often good, though the sufferer 
may be afraid to eat on account of the anticipated pain. Its association 
with ulcer has been referred to. There is commonly constipation. 

(b) Super secretion, Intermittent and Continuous. — This is a form of dys- 
pepsia which has been long recognized, but of late has been specially studied 
by Eeichmann and others. The increased flow of the gastric juice may be 
intermittent or continuous. The secretion under such circumstances is 
usually superacid, though this is not always the case. The periodical form — 
the gastroxynsis of Eossbach — may be quite independent of the time of 
digestion. Great quantities of highly acid gastric juice may be secreted 
in a very small space of time. Such cases are rare, and are especially asso- 
ciated either with profound neurasthenia or with locomotor ataxia. The 
attack may last for several days. It usually sets in with a gnawing, unpleas- 
ant sensation in the stomach, severe headache, and shortly after the patient 
vomits a clear, watery secretion of such acidity that the throat is irritated 
and made raw and' sore. As mentioned, the attacks may be quite inde- 
pendent of food. Continuous supersecretion is more common. The con- 
stant presence of fluid in the stomach, together with the pyloric spasm, 
which commonly results from the irritation of the overacid gastric juice, 



NEUROSES OF THE STOMACH. 



501 



are followed by a more or less extensive dilatation. Digestion of the starches 
is retarded, and there are eructations of acid fluid and gastric distress. 
This secretion of highly acid gastric juice may continue when the stomach is 
free from food. In these cases pain, burning acid eructations, and even 
vomiting, occurring during the night and early in the morning, are rather 
characteristic. 

(c) Nervous Subacidity or Inacidity ; Achylia Gastrica Nervosa. — Lack of 
the normal amount of acid is found in chronic catarrh, and particularly in 
cancer. As Leube has shown, a reduction in the normal amount of acid 
may exist with the most pronounced symptoms of nervous dyspepsia and 
yet the stomach will be free from food within the regular time. A condi- 
tion in which free acid is absent in the gastric juice may occur in cancer, 
in extreme sclerosis of the mucous membrane, as a nervous manifestation of 
hysteria, and occasionally of tabes. In most of these cases, though there 
be no free acid, yet the other digestive ferments — pepsin and the curdling 
ferments — or their zymogens are to be demonstrated .in the gastric juice. 
There may, however, be a complete absence of the gastric secretion. To 
these cases Einhorn has given the name of achylia gastrica. This condition 
was at first thought to occur only in cases of total atrophy of the gastric 
mucosa, but recent observations have shown that it may occur as a neurosis. 
In a case of Einhorn's the gastric secretions returned after five years of total 
achylia gastrica. 

The symptoms of subacidity, or even of achylia gastrica, vary greatly 
in intensity; they may be almost or quite absent in cases of advanced atro- 
phy of the mucosa, and, as a rule, are not marked so long as the motor 
activity of the stomach remains good. If atony, however, develop and ab- 
normal fermentative processes arise, severe gastric and intestinal symptoms 
may follow. In the cases associated with hysteria and neurasthenia, even 
though the food may be well taken care of by the intestines, there are very 
commonly grave sensory disturbances in the region of the stomach, in ad- 
dition to the general nervous symptoms. 

III. Sensory Neuroses. — (a) Hyperesthesia. — In this condition the pa- 
tients complain of fulness, pressure, weight, burning, and so forth, during 
digestion, just such symptoms as accompany a variety of organic diseases of 
the stomach, and yet in all other respects the gastric functions appear quite 
normal. Sometimes these distressing sensations are present even when the 
stomach is empty. These symptoms are usually associated with other mani- 
festations of hysteria and neurasthenia. The pain often follows particular 
articles of food. An hysterical patient may apparently suffer excruciating 
pain niter taking the smallest amount of food of any sort, while anything 
prescribed as a medicine may be well borne. In severe cases the patient 
may be reduced to an extreme degree of starvation. 

(b) Gastralgia; Gastrodynia. — Severe pains in the epigastrium, parox- 
ysmal in character, occur (a) as a manifestation of a functional neurosis, 
independent of organic disease, and usually associated with other nervous 
symptoms (it is ibis form which will here be described); (b) in chronic 
disease of the nervous system, forming the so-called gastric crises; and (c) 
in organic disease of the stomach, such as ulcer or cancer. 



502 



DISEASES OF THE DIGESTIVE SYSTEM. 



The functional neurosis occurs chiefly in women, very commonly in con- 
nection with disturbed menstrual function or with pronounced hysterical 
symptoms. The affection may set in as early as puberty, but it is more 
common at the menopause. Anaemic, constipated women who have worries 
and anxieties at home are most prone to the affection. It is more frequent 
in brunettes than in blondes. Attacks of it sometimes occur in robust, 
healthy men. More often it is only one feature in a condition of general 
neurasthenia or a manifestation of that form of nervous dyspepsia in which 
the gastric juice or hydrochloric acid is secreted in excess. I am very 
sceptical as to the existence of a gastralgia of purely malarial origin. 

The symptoms are very characteristic; the patient is suddenly seized 
with agonizing pains in the epigastrium, which pass toward the back and 
around the lower ribs. The attack is usually independent of the taking 
of food, and may recur at definite intervals, a periodicity which has given 
rise to the supposition in some cases that the affection is due to malaria. 
The most marked periodicity, however, may be in the gastralgic attacks of 
ulcer. They frequently come on at night. Vomiting is rare; more com- 
monly the taking of food relieves the pain. To this, however, there are 
striking exceptions. Pressure upon the epigastrium commonly gives relief, 
but deep pressure may be painful. It seems scarcely necessary to separate 
the forms, as some have done, into irritative and depressive, as the cases 
insensibly merge into each other. Stress has been laid upon the occurrence 
of painful points, but they are so common in neurasthenia that very little 
importance can be attributed to them. 

The diagnosis offers many difficulties. Organic disease either of the 
stomach or of the nervous system, particularly the gastric crises of loco- 
motor ataxia, must be excluded. In the case of ulcer or cancer this is not 
always easy. The fact that the pain is most marked when the stomach is 
empty and is relieved by the taking of food is sometimes regarded as pathog- 
nomonic of simple gastralgia, but to this there are many exceptions, and 
in cancer the pains may be relieved on eating. The prolonged intervals 
between the attacks and their independence of diet are important features 
in simple gastralgia; but in many instances it is less the local than the gen- 
eral symptoms of the case which enable us to make the diagnosis. It is to 
be remembered that in gall-stone colic jaundice is frequently absent, and in 
any long-standing case of gastralgia, in which the attacks recur at intervals 
for years, the question of cholelithiasis should be considered. 

(c) Anomalies of the Sense of Hunger and Repletion; Bulimia. — Ab- 
normally excessive hunger coming on often in paroxysmal attacks, which 
cause the patient to commit extraordinary excesses in eating. This condi- 
tion may occur in diabetes mellitus and sometimes in gastric disorders, par- 
ticularly those associated with supersecretion. It is, however, more com- 
monly seen in hysteria and in psychoses. It may occur in cerebral tumors, 
in Graves' disease, and in epilepsy. 

The attacks often begin suddenly at night, the patient waking with a 
feeling of faintness and pain, and an uncontrollable desire for food. Some- 
times such attacks occur immediately after a large meal. The attack may 
be relieved by a small amount of food, while at other times enormous quan- 



NEUROSES OF THE STOMACH. 



503 



tities may be taken. In obstinate cases gastritis, atony, and dilatation fre- 
quently result from the abuse of the stomach. 

Akoria. — An absence of the sense of satiety. This condition is com- 
monly associated with bulimia and polyphagia, but not always. The patient 
always feels " empty/' There are usually other well-marked manifestations 
of hysteria or neurasthenia. 

Anorexia Nervosa. — This condition, which is a manifestation of a 
neurotic temperament, is discussed subsequently under the general head- 
ing of Hysteria. 

Treatment of Neuroses of the Stomach. — The most important part of the 
treatment of nervous dyspepsia is often that directed toward the improve- 
ment of the general physical and mental condition of the patient. The 
possibility that the symptoms may be of reflex origin should be borne in 
mind. A large proportion of cases of nervous dyspepsia are dependent upon 
mental and physical exhaustion or worry, and a vacation or a change of 
scene will often accomplish what years of treatment at home have failed 
to do. The manner of life of the patient should be investigated and a 
proper amount of physical exercise in the open air insisted upon. This 
alone will in some cases be sufficient to cause the disappearance of the symp- 
toms. 

Many cases of nervous dyspepsia with marked neurasthenic or hysterical 
symptoms do well on the Weir-Mitchell treatment, and in obstinate forms 
it should be given a thorough trial. The most striking results are perhaps 
seen in the case of anorexia nervosa, which will be referred to subsequently. 
It is also of value in nervous vomiting. 

In cardiac spasm care should be taken to eat slowly, to avoid swallow- 
ing too large morsels or irritating substances. The methodical introduction 
of thick sounds may be of value. 

The treatment in atony of the stomach should be similar to that adopted 
in moderate dilatation — the administration of small quantities of food at 
frequent intervals; the limitation of the fluids, which should also be taken 
in small amounts at a time; lavage. Strychnine in full doses may be of 
value. 

In the distressing cases of hyperacidity, in addition to the treatment of 
the general neurotic condition, alkalies must be employed either in the 
form of magnesia or bicarbonate of soda. These should be given in large 
doses and at the height of digestion. The burning acid eructations may be 
relieved in this way. The diet should be mainly albuminous, and should 
lie administered in a non-irritating form. Stimulating condiments and 
alcohol should be avoided. Starches should be sparingly allowed, and only 
in mosl digestible forms. Fats are fairly well borne. 

Limiting the patient to a strictly meat diet is a valuable procedure 
in many eases of dyspepsia associated with hyperacidity. The meat should 
be taken either raw or, if an insuperable objection exists to this, very 
slightly cooked. Tt is best given finely minced or grated on stale bread. 
An ample dietary is r; : | ounces (100 grammes) of meat, two medium slices 
of stale bread, and an ounce (30 grammes) of butter. .This may he taken 
three times a day with a glass of Apollinaris water, soda water, or, what 



504 



DISEASES OF THE DIGESTIVE SYSTEM. 



is just as satisfactory, spring water. The fluid should not be taken too cold. 
Special care should be taken in the examination of the meat to guard against 
tape-worm infection, but suitable instructions on this point can be given. 
This is sufficient for an adult man, and many obstinate cases yield satis- 
factorily to a month or six weeks of this treatment, after which time the 
less readily digested articles of food may be gradually added to the dietary. 

In supersecretion the use of the stomach-tube is of the greatest value. 
In the periodical form it should be used as soon as the attack begins. The 
stomach may be washed with alkaline solutions or solutions of nitrate of 
silver. 1 to 1,000, may be used. Where this is impracticable the taking of 
albuminous food may give relief. One of my patients used to have two 
hard-boiled eggs by his bedside, by the eating of which nocturnal attacks 
were alleviated. Alkalies in large doses are also indicated. 

In cases of continued supersecretion there is usually atony and dilata- 
tion. The diet here should be much as in superacidity, but should be 
administered in smaller quantities at frequent intervals. Lavage with 
alkaline solutions or with nitrate of silver is of great value. To relieve pain 
large quantities of bicarbonate of soda or magnesia should be given at the 
height of digestion. 

In subacidity a carefully regulated, easily digestible mixed diet, not too 
rich in albuminoids, is advisable. Bitter tonics before meals are sometimes 
of value. In achylia gastrica the use of predigested foods and of hydro- 
chloric acid in full doses may be of assistance. 

In marked hyperesthesia, beside the treatment of the general condition, 
nitrate of silver in doses of gr. J— \, taken in § iij— § iv of water on an empty 
stomach, is advised by Eosenheim. 

In some instances rectal feeding may have to be resorted to. 

The gastralgia, if very severe, requires morphia, which is best admin- 
istered subcutaneously in combination with atropia. In the milder attacks 
the combination of morphia (gr. |) with cocaine and belladonna is recom- 
mended by Ewald. The greatest caution should, however, be exercised in 
these cases in the use of the hypodermic syringe. It is preferable, if opium 
is necessary, to give it by the mouth, and not to let the patient know the 
character of the drug. Chloroform, in from 10- to 20-drop doses, or Hoff- 
man's anodyne will sometimes allay the severe pains. The general condi- 
tion should receive careful attention, and in many cases the attacks recur 
until the health is restored by change of air with the prolonged use of 
arsenic. If there is anaemia iron may be given freely. Nitrate of silver in 
doses of gr. \ to \ in a large claret-glass of water taken on an empty stomach 
is useful in some cases. 

There are forms of nervous dyspepsia occurring in women who are often 
well nourished and with a good color, yet Avho suffer — particularly at night 
— with flatulency and abdominal distress. The sleep may be quiet and un- 
disturbed for two or three hours, after which they are aroused with painful 
sensations in the abdomen and eructations. The appetite and digestion may 
appear to be normal. Constipation is, however, usually present.* In many 
of these patients the condition seems rather intestinal dyspepsia, and the 
distress is due to the accumulation of gases, the result of excessive putre- 



DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHCEA. 505 



faction. The fats, starches, and sugars should be restricted. A diastase 
ferment is sometimes useful. The flatulency may be treated by the methods 
above mentioned. Naphthalin, salicylate of bismuth, and salol have been 
recommended. Some of these cases obtain relief from thorough irrigation 
of the colon at bedtime. 

The treatment of anorexia nervosa is described subsequently. 



VII. DISEASES OF THE INTESTINES. 

I. DISEASES OF THE INTESTINES ASSOCIATED WITH 

DIARRHCEA. 

CATARRHAL ENTERITIS; DIARRHCEA. 

In the classification of catarrhal enteritis the anatomical divisions of 
the bowel have been too closely followed, and a duodenitis, jejunitis, ilei- 
tis, typhlitis, colitis, and proctitis have been recognized; whereas in a 
majority of cases the entire intestinal tract, to a greater or lesser extent, is 
involved, sometimes the small most intensely, sometimes the large bowel; 
but during life it may be quite impossible to say which portion is specially 
affected. 

Etiology. — The causes may be either primary or secondary. Among 
the causes of primary catarrhal enteritis are: (a) Improper food, one of 
the most frequent, especially in children, in whom it follows overeating, 
or the ingestion of unripe fruit. In some individuals special articles of 
diet will always produce a slight diarrhoea, which may not be clue to a 
catarrh of the mucosa, but to increased peristalsis induced by the offending 
material, (b) Various toxic substances. Many of the organic poisons, such 
as those produced in the decomposition of milk and articles of food, excite 
the most intense intestinal catarrh. Certain inorganic substances, as arsenic 
and mercury, act in the same way. (c) Changes in the weather. A fall in 
the temperature of from twenty to thirty degrees, particularly in the spring 
or autumn, may induce — how, it is difficult to say — an acute diarrhoea. We 
speak of this as a catarrhal process, the result of cold or of chill. On the 
other hand, the diarrhoea! diseases of children are associated in a very spe- 
cial way with the excessive heat of summer months, (d) Changes in the 
constitution of the intestinal secretions. We know too little about the 
succus entericus to be able to speak of influences induced by change in its 
quantity or quality. It has long been held that an increase in the amount 
of bile poured into the bowel might excite a diarrhoea; hence the term 
bilious diarrhoea, so frequently used by the older writers. Possibly there 
are conditions in which an excessive amount of bile is poured into the intes- 
tine, increasing Hie peristalsis, and hurrying on the contents; but the oppo- 
site state, a scanty secretion, by favoring the natural fermentative processes, 
much more 1 commonly causes an intestinal catarrh. Absence of the pan- 
creatic secretion from the intestine has heen associated in certain cases with 



506 



DISEASES OF THE DIGESTIVE SYSTEM. 



a fatty diarrhoea, (e) Nervous influences. It is by no means clear how 
mental states act upon the bowels, and yet it is an old and trustworthy ob- 
servation, which every-day experience confirms, that the mental state may 
profoundly affect the intestinal canal. These influences should not prop- 
erly be considered under catarrhal processes, as they result simply from in- 
creased peristalsis or increased secretion, and are usually described under 
the heading nervous diarrhoea. In children it frequently follows fright, 
It is common, too, in adults as a result of emotional disturbances. Can- 
statt mentions a surgeon who always before an important operation had 
watery diarrhoea. In hysterical women it is seen as an occasional occur- 
rence, due to transient excitement, or as a chronic, protracted diarrhoea, 
which may last for months or even years. 

Among the secondary causes of intestinal catarrh may be mentioned: 
(a) Infectious diseases. Dysentery, cholera, typhoid fever, pyaemia, septi- 
caemia, tuberculosis, and pneumonia are occasionally associated with intes- 
tinal catarrh. In dysentery and typhoid fever the ulceration is in part 
responsible for the catarrhal condition, but in cholera it is probably a direct 
influence of the bacilli or of the toxic materials produced by them, (b) 
The extension of inflammatory processes from adjacent parts. Thus, in 
peritonitis, catarrhal swelling and increased secretion are always present in 
the mucosa. In cases of invagination, hernia, tuberculous or cancerous ul- 
ceration, catarrhal processes are common, (c) Circulatory disturbances 
cause a catarrhal enteritis, usually of a very chronic character. This is 
common in diseases of the liver, such as cirrhosis, and in chronic affections 
of the heart and lungs — all conditions, in fact, which produce engorgement 
of the terminal branches of the portal vessels, (d) In the cachectic condi- 
tions met with in cancer, profound anaemia, Addison's disease, and Bright 's 
disease intestinal catarrh may develop, and may terminate life. 

Morbid Anatomy. — Changes in the mucous membrane are not al- 
ways visible, and in cases in which, during life, the symptoms of intestinal 
catarrh have been marked, neither redness, swelling, nor increased secre- 
tion — the three signs usually laid down as characteristic of catarrhal inflam- 
mation — may be present post mortem. It is rare to see the mucous mem- 
brane injected; more commonly it is pale and covered with mucus. In 
the upper part of the small intestine the tips of the valvulae conniventes 
may be deeply injected. Even in extreme grades of portal obstruction in- 
tense hyperemia is not often seen. The entire mucosa may be softened and 
infiltrated, the lining epithelium swollen, or even shed, and appearing as 
large flakes among the intestinal contents. This is, no doubt, a post-mor- 
tem change. The lymph follicles are almost always swollen, particularly 
in children. The Peyer's patches may be prominent and the solitary fol- 
licles in the large and small bowel may stand out with distinctness and 
present in the centres little erosions, the so-called follicular ulcers. This 
may be a striking feature in the intestine in all forms of catarrhal enteritis 
in children, quite irrespective of the intensity of the diarrhoea. 

When the process is more chronic the mucosa is firmer, in some instances 
thickened, in others distinctly thinned, and the villi and follicles present a 
slaty pigmentation. 



DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHCEA. 507 



Symptoms. — Acute and chronic forms may be recognized. The im- 
portant symptom of both is diarrhoea, which, in the majority of instances, 
is the sole indication of this condition. It is not to be supposed that diar- 
rhoea is invariably caused by, or associated with, catarrhal enteritis, as it 
may be produced by nervous and other influences. It is probable that 
catarrh of the jejunum may exist without any diarrhoea; indeed, it is a 
very common circumstance to find post mortem a catarrhal state of the 
small bowel in persons who have not had diarrhoea during life. The stools 
vary extremely in character. The color depends upon the amount of bile 
with which they are mixed, and they may be of a dark or blackish brown, 
or of a light-yellow, or even of a grayish-white tint. The consistence is 
usually very thin and watery, but in some instances the stools are pultaceous 
like thin gruel. Portions of undigested food can often be seen (lienteric 
diarrhoea), and flakes of yellowish-brown mucus. Microscopically there 
are innumerable micro-organisms, epithelium and mucous cells, crystals of 
phosphate of lime, oxalate of lime, and occasionally cholesterin and Char- 
cot's crystals. 

Pain in the abdomen is usually present in the acute catarrhal enteritis, 
particularly when due to food. It is of a colicky character, and when the 
colon is involved there may be tenesmus. More or less tympanites exists, 
and there are gurgling noises or borborygmi, due to the rapid passage of 
fluid and gas from one part to another. In the very acute attacks there 
may be vomiting. Fever is not, as a rule, present, but there may be a 
slight elevation of one or two degrees. The appetite is lost, there is intense 
thirst, and the tongue is dry and coated. In very acute cases, when the 
quantity of fluid lost is great and the pain excessive, there may be collapse 
symptoms. The number of evacuations varies from four or five to twenty 
or more in the course of the day. The attack lasts for two or three days, 
or may be prolonged for a week or ten days. 

Chronic catarrh of the bowels may follow the acute form, or may de- 
velop gradually as an independent affection or as a sequence of obstruction 
in the portal circulation. It is characterized by diarrhoea, with or without 
colic. The dejections vary; when the small bowel is chiefly involved the 
diarrhoea is of a lienteric character, and when the colon is affected the 
stools are thin and mixed with much mucus. A special form of mucous 
diarrhoea will be subsequently described. The general nutrition in these 
chronic cases is greatly disturbed; there may be much loss of flesh and 
great pallor. The patients are inclined to suffer from low spirits, or hypo- 
chondriasis may develop. 

Diagnosis. — It is important, in the first place, to determine, if pos- 
sible, whether the large or small bowel is chiefly affected. In catarrh of 
the small bowel the diarrhoea is less marked, the pains are of a colicky char- 
acter, borborygmi are not so frequent, the faeces usually contain portions 
of food. and are more yellowish-oreon or grayish-yellow and floccnlent and 
do not coiii;] in nnieh mncns. When the large intestine is at fault there 
may he no pain whatever, as in the catarrh of the large intestine associated 
with tuberculosis and Plight's disease. When present, the pains are most 
intense and, if the lower portion of the bowel is involved, there may be 



508 



DISEASES OF THE DIGESTIVE SYSTEM. 



marked tenesmus. The stools have a uniform soupy consistence; they are 
grayish in color and granular throughout, with here and there flakes of 
mucus, or they may contain very large quantities of mucus. 

There are no positive symptoms by which the diagnosis of duodenitis 
can be made. It is usually associated with acute gastritis and, if the process 
extends into the bile-duct, with jaundice. Xeither jejunitis nor ileitis can 
be separated from general intestinal catarrh. 

ENTERITIS IX CHILDREN. 

We may recognize three forms: (1) The acute dyspeptic diarrhoea; (2) 
cholera infantum; and (3) acute entero-colitis. 

General Etiology of the Diarrhoeas of Children. — The dis- 
ease is must frequent in artificially fed children, and the greatest number 
of cases occur between the ages of six and eighteen months. A popular and 
well-founded belief ascribes special danger to the second summer of the in- 
fant. Infantile diarrhoea is very prevalent among the poorer classes in the 
large cities. It attacks, however, children with the most favorable sur- 
roundings. Two factors influence the disease, diet and temperature. An 
immense majority of all fatal cases are artificially fed. Of 1,943 fatal cases 
in Holt's statistics, only three per cent were exclusively breast fed. Among 
the poor the bowel complaint in children begins with the artificial feeding. 
The relation of temperature to the prevalence of diarrhceal diseases in chil- 
dren has long been recognized. The mortality curve begins to rise in 
May, increases in June, reaches the maximum in July, and gradually sinks 
through August and September. The maximum corresponds closely with 
the highest mean temperature; yet we cannot regard the heat itself as the 
direct agent, but only as one of several factors. Thus the mean temper- 
ature of June is only four or five degrees lower than that of July, and yet 
the mortality is not more than one third. Seibert, who has carefully ana- 
lyzed the mortality and the temperature, month by month, in Xew York, 
for ten years, fails to find a constant relation between the degree of heat 
and the number of cases of diarrhoea. Xeither barometric pressure nor 
humidity appears to have any influence. 

Relation of Bacteria. — The healthy faeces of sucklings contain a 
number of bacteria and micrococci, the most important of which are the 
bacterium lactis aerogenes and the bacterium coli commune. The former is 
only present in the intestine after a milk diet, the milk sugar appearing to 
furnish the materials necessary for its growth. It occurs rather in the 
upper portion of the bowel, and in this region excites the fermentative 
processes in the milk. The bacterium coli commune is found more abun- 
dantly in the lower portion of the small intestine and in the colon, and ex- 
cites fermentative changes which are probably associated with certain phases 
of digestion. The observations of Escherich show the remarkable simplic- 
ity of this bacterial vegetation in the healthy faeces of milk-fed children, as 
these two organisms alone develop and are constant. In infantile diarrhoea 
the number of bacteria which may be isolated from the stools is remarkable. 
Booker has discriminated forty varieties, the greatest number of which were 



DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHCEA. 509 



found in the cases of cholera infantum. The two constant forms noted 
above do not disappear in the diarrhceal stools. No forms have been found 
to bear a constant or specific relation to the diarrhceal faeces, such as the 
two above mentioned do to the healthy milk faeces. The bacteria of 
the proteus group are most frequent, and possess pathogenic properties. 
All the varieties develop and produce important changes in the milk, which 
have been dealt with very fully by Booker in his exhaustive monograph 
(Johns Hopkins Hospital Beports, vol. vi). This author concludes that in 
the diarrhoea of infants " not one specific kind, but many different kinds 
of bacteria are concerned, and that their action is manifested more in the 
alteration of the food and intestinal contents and in the production of in- 
jurious products than in a direct irritation upon the intestinal wall." With 
these agree the conclusions of Jeffries and Baginsky regarding cholera in- 
fantum. 

Morbid Anatomy. — We find most frequently a catarrhal swelling 
of the mucosa of both small and large bowel with enlargement of the lymph 
follicles. In more chronic cases the latter show small erosions or follicular 
ulcers; more rarely there is croupous enteritis affecting the lower part of 
the ileum and the colon. The changes in the other organs are neither 
numerous nor characteristic. Broncho-pneumonia occurs in many cases. 
The spleen may be swollen. Brain lesions are rare; the membranes and 
substance are often anaemic, but meningitis or thrombosis is very un- 
common. 

Clinical Forms.— Acute Dyspeptic DiarrhoBa. — The child may ap- 
pear in its usual health, but has an increase in the number of stools, with- 
out fever or special disturbance except slight restlessness at night. After 
persisting for a day or two the stools become more frequent and contain 
undigested food and curds, and are very offensive. In other cases the dis- 
ease sets in abruptly with vomiting, griping pains, and fever, which may rise 
rapidly and reach 104° or 105°. There may be convulsions at the outset. 
The abdomen is sensitive, and the child lies with the legs drawn up. The 
stools consist of grayish or greenish-yellow faeces mixed with gas, curds, and 
portions of food. In children over two years of age such attacks not infre- 
quently follow eating freely of unripe fruit or the drinking of milk which 
lias been tainted. With judicious treatment the children improve in a few 
days: but relapses are not uncommon, and in the hot weather the attack 
may be the starting point of a severe entero-colitis. In a debilitated child 
a mild attack may prove fatal. This dyspeptic diarrhoea is distinguished 
sharply from cholera infantum by the character of the stools, which never 
have a watery, serous character. In many instances this form precedes the 
onset of the specific fevers, particularly during the hot weather. 

Cholera Infantum. — This is by no means so common as the ordinary 
dyspeptic diarrhoea of children, and, according to Holt, occurs only in two 
or three pel- cent of the eases of summer diarrhoea. It prevails in the hot 
weather and in children artificially fed or who have had previously some 
slight dyspeptic derangement. It is characterized by vomiting, uncon- 
trollable diarrhoea, and collapse. The disease sets in with vomiting, which 
is incessant and is excited by an attempt to take food or drink. The stools 



510 



DISEASES OF THE DIGESTIVE SYSTEM. 



are profuse and frequent; at first faecal in character, brown or yellow in 
•color, and finally thin, serous, and watery. The stools first passed are very 
offensive; subsequently they are odorless. The thin, serous stools are alka- 
line. There is fever, but the axillary temperature may register three or 
more degrees below that of the rectum. From the outset there is marked 
prostration; the eyes are sunken, the features pinched, the fontanelle de- 
pressed, and the skin has a peculiar ashy pallor. At first restless and ex- 
cited, the child subsequently becomes heavy, dull, and listless. The tongue 
is coated at the onset, but subsequently becomes red and dry. As in all 
choleraic conditions, the thirst is insatiable; the pulse is rapid and feeble, 
and toward the end becomes irregular and imperceptible. Death may 
■occur within twenty-four hours, with symptoms of collapse and great eleva- 
tion of the internal temperature. Before the end the diarrhoea and vom- 
iting may cease. In other instances the intense symptoms subside, but the 
child remains torpid and semi-comatose with fingers clutched, and there 
may be convulsions. The head may be retracted and the respirations in- 
terrupted, irregular, and of the Cheyne-Stokes type. The child may re- 
main in this condition for some days without any signs of improvement. 
It was to this group of symptoms in infantile diarrhoea that Marshall Hall 
.gave the term " hydrencephaloid " or spurious hydrocephalus. As a rule, 
no changes in the brain or other organs are found, and the condition is no 
doubt caused by the toxic agents absorbed from the intestine. A remark- 
able condition of sclerema is described as a sequel of cholera infantum. 
The skin and subcutaneous tissues become hard and firm and the appear- 
ance has been compared to that of a half-frozen cadaver. 

Xo constant organism has been found in these cases. Baginsky con- 
siders the disease the result of the action on the system of the poisonous 
products of decomposition encouraged by the various bacteria present — a 
Faulniss disease. The clinical picture is that produced by an acute bac- 
terial infection, as in Asiatic cholera. 

The diagnosis is readily made. There is no other intestinal affection in 
children for which it can be mistaken. The constant vomiting, the fre- 
quent watery discharges, the collapse symptoms, and the elevated temper- 
ature make an unmistakable clinical picture. The outlook in the majority 
•of cases is bad, particularly in children artificially fed. Hyperpyrexia, ex- 
treme collapse, and incessant vomiting are the most serious symptoms. 

Acute Eiltero-colitis. — In this form the ileum and colon are most af- 
fected, chiefly in the lymph follicles, hence the term follicular enteritis or 
follicular dysentery. Catarrhal ulceration is a common sequence. It oc- 
curs most frequently in warm weather, in artificially fed children; but it 
may set in at any season of the year, and is the form ■ of enteritis most 
common as a secondary complication in the specific fevers of childhood. 

The attack may follow the ordinary dyspeptic diarrhoea. The temper- 
ature increases, the stools change in character and contain traces of blood 
and mucus, the former usually only in streaks. The faeces are passed with- 
out any pain. The abdomen is distended and tender along the line of the 
•colon. Vomiting may be present at the outset, but is not a characteristic 
feature, as in cholera infantum. The diarrhoea may be gradually checked 



DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHCEA. 5H 

and convalescence is established in two or three weeks; in other instances 
the disease becomes subacute, the fever subsides, but the diarrhoea persists 
and the general health of the child rapidly deteriorates. The case may 
drag on for five or six weeks, when improvement gradually occurs or the 
child is carried off by a severe intercurrent attack. In a third form of 
acute entero-colitis, in which anatomically the lesions are those already 
mentioned — namely, an intense follicular inflammation — the symptoms are 
of a more severe character, and the affection is sometimes spoken of as acute 
dysentery. It attacks children up to the third or fourth year or even older. 
The onset is sudden, with high fever, vomiting, frequent stools, which at 
first contain remnants of food and fseces and subsequently much mucus and 
some blood. There is incessant pain, which may be more severe than in 
any intestinal affection of childhood. The prostration is very great and 
the fatal termination may occur within forty-eight hours. More commonly 
the case lasts for a week or longer. 

The Coeliac Affection. — Under this heading Gee has described an intes- 
tinal disorder, most commonly met with in children between the ages of 
one and five, characterized by the occurrence of pale, loose stools, not un- 
like gruel or oatmeal porridge. They are bulky, not watery, yeasty, frothy, 
and extremely offensive. The affection has received various names, such as 
diarrhoea alba or diarrhoea chylosa. It is not associated with tuberculous 
or other hereditary disease. It begins insidiously and there are progressive 
wasting, weakness, and pallor. The belly becomes doughy and inelastic. 
There is often flatulency. Fever is usually absent. The disease is linger- 
ing and a fatal termination is common. So far nothing is known of the 
pathology of the disease. Ulceration of the intestines has been met with, 
but it is not constant. 

Sprue or Psilosis. — A remarkable disease of the tropics, character- 
ized by " a peculiar, inflamed, superficially ulcerated, exceedingly sensitive 
condition of the mucous membrane of the tongue and mouth; great wast- 
ing and anaemia; pale, copious, and often loose, frequent, and frothy fer- 
menting stools; very generally by more or less diarrhoea; and also by a 
marked tendency to relapse " (Manson). 

It is very prevalent in India, China, and Java. Nothing definite is 
known as to its cause. 

W hen fully established the chief symptoms are a disturbed condition of 
the bowels, pale, yeasty-looking stools, a raw, bare, sore condition of the 
tongue, mouth, and gullet, sometimes with actual superficial ulceration. 
With these gastro-intestinal symptoms" there are associated anaemia and 
general wasting. It is very chronic, with numerous relapses. There are 
no characteristic anatomical changes. There are usually ulcers in the 
colon, and the French think it is a form of dysentery. 

Mansor recommends rest and a milk diet as curative in a large propor- 
tion of the eases. The recent monograph by Thin and the article by Man- 
son in Allbutt's System give very full descriptions of the disease. 



82 



512 



DISEASES OF THE DIGESTIVE SYSTEM. 



DIPHTHERITIC OR CROUPOUS ENTERITIS. 

A croupous or diphtheritic inflammation of the mucosa of the small 
and large intestines occurs (a) most frequently as a secondary process in the 
infectious diseases — pneumonia, pyaemia in its various forms, and typhoid 
fever; (b) as' a terminal process in many chronic affections, such as Bright's 
disease, cirrhosis of the liver, or cancer; and (c) as an effect of certain poi- 
sons — mercury, lead, and arsenic. • 

There are three different anatomical pictures. In one group of cases 
the mucosa presents on the top of the folds a thin grayish-yellow diph- 
theritic exudate situated upon a deeply congested base. In some cases all 
grades may be seen between the thinnest film of superficial necrosis and in- 
volvement of the entire thickness of the mucosa. In the colon similar 
transversely arranged areas of necrosis are seen situated upon hyperaemic 
patches, and it may be here much more extensive and involve a large por- 
tion of the membrane. There may be most extensive inflammation without 
any involvement of the solitary follicles of the large or small bowel. 

In a second group of cases the membrane has rather a croupous character. 
It is grayish white in color, more flake-like and extensive, limited, perhaps, 
to the caecum or to a portion of the colon; thus, in several cases of pneumonia 
I found this flaky adherent false membrane, in one instance forming patches 
1 to 2 cm. in diameter, which in form were not unlike rupia crusts. 

In a third group the affection is really a follicular enteritis, involving 
the solitary glands, which are swollen and capped with an area of diph- 
theritic necrosis or are in a state of suppuration. Follicular ulcers are com- 
mon in this form. The disease may run its course without any symptoms, 
and the condition is unexpectedly met with post mortem. In other in- 
stances there are diarrhoea, pain, but not often tenesmus or the passage of 
blood-stained mucus. In the toxic cases the intestinal symptoms may be 
very marked, but in the terminal colitis of the fevers and of constitutional 
affections the symptoms are often trifling. 

The ulcerative colitis of chronic disease may be only a terminal event 
in these diphtheritic processes. 

PHLEGMONOUS ENTERITIS. 
As an independent affection this is excessively rare, even less frequent 
than its counterpart in the stomach. It is seen occasionally in connection 
with intussusception, strangulated hernia, and chronic obstruction. Apart 
from these conditions it occurs most frequently in the duodenum, and leads 
to suppuration in the submucosa and abscess formation. Except when 
associated with hernia or intussusception the affection cannot be diagnosed. 
The symptoms usually resemble those of peritonitis. 

ULCERATIVE ENTERITIS. 

In addition to the specific ulcers of tuberculosis, syphilis, and typhoid 
fever, the following forms of ulceration occur in the bowels: 

(a) Follicular Ulceration. — As previously mentioned, this is met with 
very commonly in the diarrhceal diseases of children, and also in the sec- 
ondary or terminal inflammations in many fevers and constitutional disor- 



DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHCEA. 51 3 



ders. The ulcers are small, punched out, with sharply cut edges, and they 
are usually limited to the follicles. With this form may be placed the 
catarrhal ulcers of some writers. 

(b) Stercoral ulcers, which occur in long standing cases of constipation. 
Very remarkable indeed are the cases in which the sacculi of the colon be- 
come filled with rounded small scybala, some of which produce distinct 
ulcers in the mucous membrane. The faecal masses may have lime salts 
deposited in them, and thus form little enteroliths. 

(c) Simple Ulcerative Colitis. — This affection, which clinically is char- 
acterized by diarrhoea, is often regarded wrongly as a form of dysentery. 
It is not a very uncommon affection, and is most frequently met with in 
men above the middle period of life. The ulceration may be very exten- 
sive, so that a large proportion of the mucosa is removed. The lumen of 
the colon is sometimes greatly increased, and the muscular walls hyper- 
trophied. There are instances in which the bowel is contracted. Fre- 
quently the remnants of the mucosa are very dark, even black, and there 
may be polypoid outgrowths between the ulcers. 

These cases rarely come under observation at the outset, and it is diffi- 
cult to speak of the mode of origin. They are characterized by diarrhoea 
of a lienteric rather than of a dysenteric character. There is rarely blood or 
pus in the stools. Constipation may alternate with the diarrhoea. There 
is usually great impairment of nutrition, and the patients get weak and 
sallow. Perforation occasionally occurs. 

The disease may prove fatal, or it may pass on and become chronic. 
The affection was not very infrequent at the Philadelphia Hospital, and 
though the disease bears some resemblance to dysentery, it is to be sepa- 
rated from it. Some of the cases which we have learned to recognize as 
amoebic dysentery resemble this form very closely. An excellent descrip- 
tion of it is given by Hale White in Allbutt's System. The ulcerative 
colitis met with in institutions, such as that described by Gemmel, of the 
Lancaster Asylum, in a recent monograph, seems to be a true dysentery. 
Dickinson has described what he calls albuminuric ulceration of the bowels 
in cases of contracted kidney. 

(d) Ulceration from External Perforation. — This may result from the 
erosion of new growths or, more commonly, from localized peritonitis 
with abscess formation and perforation of the bowel. This is met with 
most frequently in tuberculous peritonitis, but it may occur in the 
abscess which follows perforation of the appendix or suppurative or 
gangrenous pancreatitis. Fatal haemorrhage may result from the perfora- 
tion. 

(e) Cancerous Ulcers. — In very rare instances of multiple cancer or sar- 
coma the submucous nodules break down and ulcerate. In one case the 
ileum contained eight or ten sarcomatous ulcers secondary to an extensive 
sarcoma in the neighborhood of the shoulder-joint. 

(/) Occasionally a solitary ulcer is met with in the caecum or colon, which 
may lead to perforation. Two instances of ulcer of the caecum, both with 
perforation, have come under my observation, and in one instance a simple 
ulcer of the colon perforated and led to fatal peritonitis. 



514 



DISEASES OF THE DIGESTIVE SYSTEM. 



Diagnosis of Intestinal Ulcers. — As a rule, diarrhoea is present 
in all cases, but exceptionally there may be extensive ulceration, particu- 
larly in the small bowel, without diarrhoea. Very limited ulceration in the 
colon may be associated with frequent stools. The character of the dejec- 
tions is of great importance. Pus, shreds of tissue, and blood are the most 
valuable indications. Pus occurs most frequently in connection with ulcers 
in the large intestine, but when the bowel alone is involved the amount is 
rarely great, and the passage of any quantity of pure pus is an indication 
that it has come from without, most commonly from the rupture of a peri- 
cecal abscess, or in women of an abscess of the broad ligament. Pus may 
also be present in cancer of the bowel, or it, may be due to local disease in 
the rectum. A purulent mucus may be present in the stools in cases of ulcer, 
but it has not the same diagnostic value. The swollen, sago-like masses 
of mucus which are believed by some to indicate follicular ulceration are 
met with also in mucous colitis. Haemorrhage is an important and valu- 
able symptom of ulcer of the bowel, particularly if profuse. It occurs 
under so many conditions that taken alone it may not be specially signifi- 
cant, but with other coexisting circumstances it may be the mast important 
indication of all. 

Fragments of tissue are occasionally found in the stools in ulcer, par- 
ticularly in the extensive and rapid sloughing in dysenteric processes. 
Definite portions of mucosa, shreds of connective tissue, and even bits of 
the muscular coat may be found. Pain occurs in many cases, either of a 
diffuse, colicky character, or sometimes, in the ulcer of the colon, very lim- 
ited and well defined. 

Perforation is an accident liable to happen when the ulcer extends 
deeply. In the small bowel it leads to a localized or general peritonitis. 
In the large intestine, too, a fatal peritonitis may result, or if perforation 
takes place in the posterior wall of the ascending or descending colon, the 
production of a large abscess cavity in the retro-peritonaeum. In a case 
at the University Hospital, Philadelphia, there was a perforation at the 
splenic flexure of the colon with an abscess containing air and pus — a con- 
dition of subphrenic pyo-pneumothorax. 

Treatment of the Previous Conditions. 

(a) Acute Dyspeptic Diarrhoea. — All solid food should be withheld. If 
vomiting is present ice may be given, and small quantities of milk and soda 
water may be taken. If the attack has followed the eating of large quan- 
tities of undigestible material, castor oil or calomel is advisable, but is not 
necessary if the patient has been freely purged. If the pain is severe, 20 
drops of laudanum and a drachm of spirits of chloroform may be given, or, 
if the colic is very intense, a hypodermic of a quarter of a grain of morphia. 
It is not well to check the diarrhoea unless it is profuse, as it usually stops 
spontaneously within forty-eight hours. If persistent, the aromatic chalk 
powder or large doses of bismuth (30 to 40 grains) may be given. A small 
enema of starch (2 ounces) with 20 drops of laudanum, every six hours, is 
a most valuable remedy. 

(b) Chronic diarrhoea, including chronic catarrh and ulcerative enter- 
itis. It is important, in the first place, to ascertain, if possible, the cause 



DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHCEA. 515 



and whether ulceration is present or not. So much in treatment depends 
upon the careful examination of the stools — as to the amount of.- mucus, 
the presence of pus, the occurrence of parasites, and, above all, the state of 
digestion of the food — that the practitioner should pay special attention 
to them. Many cases simply require rest in bed and a restricted diet. 
Chronic diarrhoea of many months' or even of several years' duration may 
be sometimes cured by strict confinement to bed and a diet of boiled milk 
and albumen water. 

In that form in which immediately after eating there is a tendency to 
loose evacuations it is usually found that some one article of diet is at 
fault. The patient should rest for an hour or more after meals. Some- 
times this alone is sufficient to prevent the occurrence of the diarrhoea. 
In those forms which depend upon abnormal conditions in the small intes- 
tine, either too rapid peristalsis or faulty fermentative processes, bismuth 
is indicated. It must be given in large doses — from half a drachm to a 
drachm three times a day. The smaller doses are of little use. Naphthalin 
preparations here do much good, given in doses of from 10 to 15 grains (in 
capsule) four or five times a day. Larger doses may be needed. Salol and 
the salicylate of bismuth may be tried. 

An extremely obstinate and intractable form is the diarrhoea of hyster- 
ical women. A systematic rest cure will be found most advantageous, and 
if a milk diet is not well borne the patient may be fed exclusively on egg 
albumen. The condition seems to be associated in some cases with in- 
creased peristalsis, and in such the bromides may do good, or preparations 
of opium may be necessary. There are instances which prove most obsti- 
nate and resist all forms of treatment, and the patient may be greatly re- 
duced. A change of air and surroundings may do more than medicines. 

In a large group of the chronic diarrhoeas the mischief is seated in the 
colon and is due to ulceration. Medicines by the mouth are here of little 
value. The stools should be carefully watched and a diet arranged which 
shall leave the smallest possible residue. Boiled or peptonized milk may 
be given, but the stools should be examined to see whether there is an 
excess of food or of curds. Meat is, as a rule, badly borne in these cases. 
The diarrhoea is best treated by enemata. The starch and laudanum should 
be tried, but when ulceration is present it is better to use astringent injec- 
tions. From 2 to 4 pints of warm water, containing from half a drachm 
to a drachm of nitrate of silver, may be used. In the chronic diar- 
rhoea which follows dysentery this is particularly advantageous. In giving 
large injections the patient should be in the dorsal position, with the hips 
elevated, and it is best to allow the injection to flow in gradually from a 
siphon bag. In this way the entire colon can be irrigated and the patient 
can retain the injection for some time. The silver injections may be very 
painful, lint they are invaluable in all forms of ulcerative colitis. Acetate 
of lead, boracic acid, sulphate of copper, sulphate of zinc, and salicylic acid 
may be used in 1-per-cent solutions. 

In the intense forms of choleraic diarrhoea in adults associated with 
constant vomiting and frequent watery discharges the patient should be 
given at once a hypodermic of a quarter of a grain of morphia, which should 



516 



DISEASES OF THE DIGESTIVE SYSTEM. 



be repeated in an hour if the pains return or the purging persists. This 
gives prompt relief, and is often the only medicine needed in the attack. 
The patient should be given stimulants, and, when the vomiting is allayed 
by suitable remedies, small quantities of milk and lime water. 

(c) The Diarrhoea of Children. — Hygienic management is of the first 
importance. The effect of a change from the hot, stifling atmosphere of a 
town to the mountains or the sea is often seen at once in a reduction in 
the number of stools and a rapid improvement in the physical condition. 
Even in cities much may be done by sending the child into the parks or 
for daily excursions on the water. However extreme the condition, fresh 
air is indicated. The child should not be too thickly clad. Many mothers, 
even in the warm weather, clothe their children too heavily. Bathing is 
of value in infantile diarrhoea, and when the fever rises above 102.5° the 
child should be placed in a warm bath, the temperature of which may be 
gradually reduced, or the child is kept in the bath for twenty minutes, by 
which time the water is sufficiently cooled. Much relief is obtained by 
the application of ice-cold cloths or of the ice-cap to the head. Irrigation 
of the colon with ice-cold water is sometimes favorable, but it has not the 
advantage of the general bath, the beneficial effect of which is seen, not only 
in the reduction of the temperature, but in a general stimulation of the 
nervous system of the child. 

Dietetic Treatment. — In the case of a hand-fed child it is important, if 
possible, to get a wet-nurse. While fever is present, digestion is sure to be 
much disturbed, and the amount of food should be restricted. If water 
or barley water be given the child will not feel the deprivation of food so 
much. When the vomiting is incessant it is much better not to attempt 
to give milk or other articles of food, but let the child take the water when- 
ever it will. 

In the dyspeptic diarrhoeas of infants, practically the whole treatment 
is a matter of artificial feeding, and there is no subject in medicine on 
which it is more difficult to lay down satisfactory rules. The studies of 
Eoteh on modified milk have revolutionized the artificial feeding of infants, 
and the establishment of the Walker-Gordon laboratories in various cities 
has been a great boon to the public and the profession. No doubt within 
a few years the study of the bacterial processes going on in the intestines 
of the child will give us most important suggestions. From his observa- 
tions Escherich lays down the following rules, recognizing two well-defined 
forms of intestinal fermentation — the acid and the alkaline: If there is 
much decomposition, with foul, offensive stools, the albuminous articles 
should be withheld from the diet and the carbohydrates given, such as dex- 
trin foods, sugar, and milk, which, on account of its sugar, ranks with the 
carbohydrates. If there is acid fermentation, with sour but not fetid stools, 
an albuminous diet is given, such 1 as broths and egg albumen. It is, 
however, by no means certain whether the reaction of the stools, upon 
which this author relies, is a sufficient test of the nature of the intestinal 
fermentation. In the dyspeptic diarrhoeas of artificially fed infants it is 
best, as a rule, to withhold milk and to feed the child, for the time at least, 
on egg albumen, broths, and beef juices. To prepare the eg£ albumen, the 



DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHOEA. 517 



whites of two or three eggs may be stirred in a pint of water and a tea- 
spoonful of brandy and a little salt mixed with it. The child will usually 
take this freely, and it is both stimulating and nourishing. It is some- 
times remarkable with what rapidity a child which has been fed on artificial 
food and milk will pick up and improve on this diet alone. Beef-juice is 
obtained by pressing with a lemon-squeezer fresh steak, previously minced 
and either uncooked or slightly broiled. This may be given alternately 
with the egg albumen or it may be given alone. Mutton or chicken broth 
will be found equally serviceable, but it is prepared with greater difficulty 
and contains more fat. In the preparation, a pound of mutton, chicken, or 
beef, carefully freed from fat, is minced and placed in a pint of cold water 
and allowed to stand in a glass jar on ice for three or four hours. It should 
then be cooked over a slow fire for at least three hours, and, after being 
strained, allowed to cool; the fat is then skimmed off and sufficient salt 
added; it may then be given either warm or cold. These naturally prepared 
albumin foods are very much to be preferred to the various artificial sub- 
stances. There is no form of nourishment so readily assimilated and apt to 
cause so little disturbance as egg albumen or the simple beef juices. The 
child should be fed every two hours, and in the intervals water may be freely 
given. It cannot be expected that, with the digestion seriously impaired, 
as much food can be taken as in health, and in many instances we see the 
diarrhoea aggravated by persistent over feeding. When the child's stomach 
is quieted and the diarrhoea checked there may be a gradual return to the 
milk diet. The milk should be sterilized, and in institutions and in cities 
this simple prophylactic measure is of the very first importance and is 
readily carried out by means of the Arnold steam sterilizer. The milk 
should be at first freely diluted — four parts of water to one of milk, which 
is perhaps the preferable w>ay — or it may be peptonized. The stools should 
be examined daily, as important indications may be obtained from them. 
Milk-whey and forms of fermented milk are sometimes useful and may be 
employed when the stomach is very irritable. These general directions as 
to food also hold good in cholera infantum. 

Medicinal Treatment. — The first indication in the dyspeptic diarrhoea 
of children is to get rid of the decomposing matter in the stomach and in- 
testines. The diarrhoea and vomiting partially effect this, but it may be 
more thoroughly accomplished, so far as the stomach is concerned, by irri- 
gation. It may seem a harsh procedure in the case of young infants, but in 
reality, with a large-sized soft-rubber catheter, it is practised without any 
difficulty. By means of a funnel, lukewarm water is allowed to pass in and 
out until it comes away quite clear. I can speak in the very warmest man- 
ner of the good results obtained by this simple procedure in cases of the 
most obstinate gastro-intestinal catarrh in children. In most cases the 
warm water is sufficient. In some hands this method has probably boon 
carried to excess, but that does not detract from its great value in suitable 
cases. To remove the fermenting substances from the intestines, doses of 
calomel or gray powder may be administered. The castor oil is equally 
efficacious, but is more apt to be vomited. Irrigation of the large bowel is 
useful, and not only thoroughly removes fermenting substances, but cleanses 



518 



DISEASES OF THE DIGESTIVE SYSTEM. 



the mucosa. The child should be placed on the back with the hips ele- 
vated. A flexible catheter is passed for from 6 to 8 inches and from 
a pint to 2 pints of water allowed to flow in from a fountain syringe. 
A pint will thoroughly irrigate the colon of a child of six months and a 
quart that of a child of two years. The water may be lukewarm, but when 
there is high fever ice-cold water may be used. In cases of entero-colitis 
there may be injections with borax, a drachm to the pint, or dilute nitrate 
of silver, which may be either given in large injections, as in the adult, or 
in quantities of 3 or 4 ounces with 3 grains of nitrate of silver to the ounce. 
These often cause very great pain, and it is well in such cases to follow the 
silver injection with irrigations of salt solution, a drachm to a pint. 

We are still without a reliable intestinal antiseptic. Neither naphtha- 
lin, salol, resorcin, the salicylates, nor mercury meets the indications. As 
in the diarrhoea of adults, bismuth in large doses is often very effective, 
but practitioners are in the habit of giving it in doses which are quite in- 
sufficient. To be of any service it must be used in large doses, so that an 
infant a year old will take as much as 2 drachms in the day. The gray 
powder has long been a favorite in this condition and may be given in 
half-grain doses every hour. It is perhaps preferable to calomel, which 
may be used in small doses of from one tenth to one fourth of a grain every 
hour at the onset of the trouble. The sodium salicylate (in doses of 2 or 
3 grains every two hours to a child a year old) has been recommended. 

In cholera infantum serious symptoms may develop with great rapidity, 
and here the incessant vomiting and the frequent purging render the ad- 
ministration of remedies extremely difficult. Irrigation of the stomach 
and large bowel is of great service, and when the fever is high ice-water 
injections may be used or a graduated bath. As in the acute choleraic 
diarrhoea of adults, morphia hypodermically is the remedy which gives 
greatest relief, and in the conditions of extreme vomiting and purging, with 
restlessness and collapse symptoms, this drug alone commands the situation. 
A child of one year may be given from to of a grain, to be repeated 
in an hour, and again if not better. When the vomiting is allayed, at- 
tempts may be made to give gray powder in half-grain doses with y 1 ^ 
of Dover's powder. Starch (§ ij) and laudanum (TT[ ij-iij) injections, if re- 
tained, are soothing and beneficial. The combination of bismuth with 
Dover's powder will also be found beneficial. No attempt should be made 
to give food. Water may be allowed freely, even when ejected at once by 
vomiting. Small doses of brandy or champagne, frequently repeated and 
given cold, are sometimes retained. When the collapse is extreme, hypo- 
dermic injections of 1-per-cent saline solution may be used as recommended 
in Asiatic cholera, and hypodermic injections of ether and brandy may be 
tried. The convalescence requires very careful management, as many cases 
pass on into the condition of entero-colitis. When the intense symptoms 
have subsided, the food should be gradually given, beginning with tea- 
spoonful doses of egg albumen or beef-juice. It is best to withhold milk 
for several days, and when used it should be at first completely peptonized 
or diluted with gruel. A teaspoonful of raw, scraped meat three or four 
times a day is often well borne. 



APPENDICITIS. 



519 



II. APPENDICITIS. 

Inflammation of the vermiform appendix is the most important of acute 
intestinal disorders. Formerly the " iliac phlegmon " was thought to be 
due to disease of the caecum — typhlitis — and of the peritonaeum covering 
it — perityphlitis; but we now know that with rare exceptions the caecum 
itself is not affected, and even the condition formerly described as stercoral 
typhlitis is in reality appendicitis. The recognition of the importance of 
appendicitis is due largely to the work of the American physicians and sur- 
geons — to Pepper, who described in 1883 the relapsing form; to Fitz, 
whose exhaustive article in 1886 served to put the whole question on a 
rational basis; to Willard Parker, who was the first to advocate early oper- 
ation; and to Sands, Bull, McBurney, Weir, Morton, Keen, Senn, J. Wil- 
liam White, Deaver, and others, who have done so much to improve the op- 
erative measures for its relief. Treves, of London, has been foremost in 
advocating the proper surgical treatment of the disease. The interest at- 
tached to the subject is manifest from the appearance within a few years of 
a number of special monographs by Kelynack, Talamon, Fowler, Sonnen- 
berg, Hawkins, Deaver, and Mynter. 

Anatomy. — The appendix veriformis is a functionless relic of a large 
ancestral caecum. It measures usually about 3 inches in length, but 
it may be scarcely an inch. The diameter is about one fourth of an inch. 
In a majority of instances it has a triangular-shaped meso-appendix, usually 
shorter than the tube, which thus becomes a little curled or bent upon 
itself. There is often a small lymph-gland just at the root of its mesentery. 
The position of the appendix is very variable. The most common direc- 
tion it assumes is upward and inward, the tip pointing toward the spleen. 
The position next in frequency is behind the caecum, and next passing over 
the pelvic brim. It may be met with, however, in almost every region of 
the abdomen, and adherent to almost every organ in it. I have seen it in 
close contact with the bladder, adherent to one ovary and the broad liga- 
ment; in the central portion of the abdomen close to the navel; in contact 
with the gall-bladder, passing out at right angles and adherent to the sig- 
moid flexure to the left of the middle line of the abdomen; and in one case 
it entered with the caecum the inguinal canal, curved upon itself, re-entered 
the abdomen, and was adherent to the wall of an abscess cavity just to the 
right of the promontory of the sacrum. The structure of the appendix is 
almost identical with that of the caecum; it is particularly rich in lymphoid 
tissue. The blood supply is derived from a small artery which passes 
along the free edge of its mesentery. 

Morbid Anatomy and Etiology. — The following are the most 
common morbid conditions: 

(a) Faecal Concretions.— The lumen of the appendix may contain a 
mould of faeces, which can readily be squeezed out. Even while soft the 
contents of the tube may be moulded in two or three sections with rounded 
ends. Concretions — enteroliths, eoproliths — are also common. The mode 
of formation is not very clear. Possibly, as with gall-stones, the micro- 



520 



DISEASES OF THE DIGESTIVE SYSTEM. 



organisms may have a favoring influence. Of 700 cases of foreign bodies 
there were 45 per cent of fascal concretions (J. F. Mitchell, J. H. H. Bul- 
letin, vol. x). The enteroliths often resemble in shape date-stones. The 
importance of these concretions is shown by the great frequency with which 
they are found in all acute inflammations of the appendix. 

(b) Foreign Bodies. — Of 1,400 cases of appendicitis collected by J. F. 
Mitchell these were present in seven per cent; in 28 cases pins were 
found. Only two instances came under my observation in ten years' 
pathological work in Montreal; in one there were eight snipe-shot and 
in another five apple-pips. The stones and seeds of various fruits, and 
bits of bone, have also been found. It is well to bear in mind that 
some of the concretions bear a very striking resemblance to cherry and 
date stones. 

(c) Obliterative Appendicitis. — The entire tube is thickened, the peri- 
toneal surface smooth or injected, and either with adhesions from slight 
circumscribed peritonitis, or perfectly free. The mucosa may show noth- 
ing more than a shedding of epithelium with infiltration of leucocytes in 
the submucosa, while in more chronic cases there is almost complete den- 
udation of the mucosa, which is replaced by granulation tissue. The mus- 
cular coats are thickened throughout, and the entire tube is firm and stiff, 
as if in a state of erection. When laid open longitudinally it at once as- 
sumes a rolled form in the reverse direction. 

The term catarrhal, which has been applied to this condition, is scarcely 
appropriate, since the changes are diffuse throughout the whole tube. In 
the majority of instances the term appendicitis obliterans, used by Senn, 
is in reality more appropriate. As Hawkins remarks, this condition is 
probably a fertile source of local peritonitis, and one may see in this stage 
fresh adhesions on the peritoneal surface or more extensive circumscribed 
peritonitis. It may, however, be, as he says, the precursor of complete im- 
munity from such attacks. " For if by the pressure of the surrounding 
parts the opposed granulating surfaces are brought into contact, and if the 
whole organ remains at rest, union may take place, and the appendix as a 
source of disease then ceases to exist. In other cases obliteration of the 
lumen cannot take place on account of the rigid incollapsible character of 
the walls, and it is this condition of chronic appendicitis which may lead 
to recurrences of attacks of colic and local symptoms in the right iliac 
fossa." 

McBurney lays great stress upon the narrowing of the lumen as pre- 
venting normal drainage of the tube and establishing conditions favorable 
for the development of septic processes. 

Obliterative appendicitis is met with in about 2 per cent of all sub- 
jects. When the stricture occurs at the csecal end of the tube the lumen 
may become greatly dilated, forming a cystic appendix which may reach 
the size of the thumb, or even that of an ordinary sausage. The con- 
tents of the cyst are either clear fluid or pus. Ulceration and perforation 
are very apt to occur. Obliterative appendicitis may go on as an ordinary 
involution process without causing any symptoms, but in many instances 
there are attacks of pain — appendicular colic; in others, exacerbations of 



APPENDICITIS. 



521 



fever with pain and swelling; while in others again ulceration and perfora- 
tion may take place. 

(d) Ulcerative Appendicitis. — Local ulceration in the appendix is met 
with as a result of the presence of concretions or of foreign bodies, or as 
the result of the action of certain micro-organisms, either those normally 
inhabiting the caecum or, under certain circumstances, the typhoid and 
tubercle bacilli. Faecal concretions and foreign bodies are met with in the 
appendix without apparently causing the slightest abrasion of its mucosa. 
In other cases the enterolith has caused atrophy of the mucous membrane 
with which it is in contact. In other cases again, the concretion or foreign 
body may be pocketed in an ulcer at the tip of the appendix, from, which 
it may be shelled out. These conditions may be present without adhe- 
sions and without reddening of the serous surface, but one not infrequently 
sees thickening of the peritonaeum with adhesions to the adjacent parts in 
ulcerative appendicitis. 

Tuberculosis of the appendix is by no means uncommon. Ulceration 
in typhoid fever is also frequently met with; in a series of 80 autopsies 
there were 3 instances of perforation of the appendix by a typhoid ulcer. 
An actinomycotic ulcer has also been described. 

(e) Necrosis and Sloughing of the Appendix— Acute Infective Appendi- 
citis. — Following upon the conditions described under (c) and (d), necrosis 
and sloughing may take place either in a limited portion of the appendix 
with perforation, or en masse without perforation, in both cases leading to 
the most intense peritonitis, localized or general. Most commonly the gan- 
grene is localized to one spot, either at the tip or in some portion of the 
tube. Usually the organ is swollen; the color may be reddish brown, black, 
or greenish yellow. Necrosis may occur en masse, and the entire appendix 
may indeed slough off from the caecum and lie free in an abscess cavity. 
In one remarkable case operated upon by my colleague, Halsted, the appen- 
dix, between 4 and 5 inches in length, was shrunken, blackish brown in 
color, sphacelated throughout, and looked like a desiccated earthworm. 

These active processes leading to ulceration and necrosis are due to the 
action of micro-organisms, and much work has been done to determine 
their character. Hodenpyl showed that the bacillus coli communis was 
present in a very large number of cases of appendicitis. In 61 cases of 
peritoneal inflammation consequent upon disease of the appendix the ba- 
cillus coli communis was found in 57, and in 50 of these it was the only 
organism present. The streptococcus pyogenes and the staphylococcus 
pyogenes aureus, the proteus and bacillus pyocyaneus have also been found. 
The streptococcus infection is the most virulent. Probably too much stress 
has been laid upon the bacillus coli communis as a cause of infective pro- 
cesses in and about the appendix. In many cases, with slight fresh adhe- 
sion and a little sero-fibrin, the cultures are negative. As Welch remarks, 
" There is reason to believe that the highly resistant colon bacillus may 
survive in an. inflamed part after the primary organism which started the 
trouble lias died out, or has been crowded out by the invader." The prone- 
ness of the appendix to infective inflammation of this sort lies "in that 
subtle structure which determines the degree of resistance of a tissue to dis- 



522 



DISEASES OF THE DIGESTIVE SYSTEM. 



ease. One man differs from another in his power of resistance; the more 
degenerate the man the less resistance can he exert. In like manner, one 
organ in a man differs from another. And in the appendix we are dealing 
with an organ which is degenerate and functionless from first to last, and 
its scanty power of resistance to bacterial invasion is but another way of 
expressing this fact " (Hawkins). 

It has been urged that the anatomical relations of the meso-appendix 
and the adjacent peritoneal folds are such that distention of the caecum, 
or of the lower portion of the ileum, may cause dragging with torsion and in- 
terfere seriously with the blood supply of the tube. The swelling of the 
mucosa so induced may be an important factor in the infection of its tissues. 

For the best recent study of the morbid anatomy of appendicitis the 
student is referred to A. 0. J. Kelly's section in the second edition of 
Deaver's work. 

Immediate Effects of the Perforation, (a) Acute General Peritonitis.— 

If the appendix is free, without adhesions, the perforation may lead at once 
to a widespread peritonitis. The inflammation varies much in virulence, 
depending apparently upon the infecting organism. The worst cases are 
those in which the streptococcus pyogenes is present, A general peritonitis 
is more common in the acute infective appendicitis than in the other forms. 
It probably results less frequently from direct perforation, or sloughing of 
the appendix, than from extension of inflammation from a local periap- 
pendicular abscess. 

(b) Localized Peritonitis, with Abscess. — Perforation leads usually to 
the formation of a circumscribed intra-peritoneal abscess cavity, which 
varies in situation with the position of the appendix, and in size from a 
walnut to a cocoanut. Perhaps the most common situation is on the psoas 
muscle, just at the angle between the ileum and the caecum. The perfo- 
rated appendix, however, may be within the pelvis, or upon the promontory 
of the sacrum, or lie between the coils of small bowel in the neighborhood 
of the umbilicus. A common situation for the large circumscribed intra- 
peritoneal abscess is in the iliac region midway between the navel and the 
anterior superior spine. Perforation, adhesive peritonitis, and the produc- 
tion of a localized abscess may proceed without causing any serious symp- 
toms, and the condition may be found when death has resulted from acci- 
dent or from some intercurrent affection. The contents of the abscess 
may be a grayish yellow, thick pus, usually with a strong faecal odor; but 
in the old, limited, small abscesses it is usually dark gray in color, and hor- 
ribly offensive. The appendix may be found free in the localized abscess; 
in other instances it is so covered with pus and inflammatory exudate that 
it is impossible to find it. While in a majority of all instances the abscess 
cavity, even when large, is intra-peritoneal, there may be — 

(c) Extensive Extra-Peritoneal Suppuration. — When an appendix perfo- 
rates, it lies, of course, in immediate contact with the peritonaeum; if on 
the iliac fascia, or the wall of the pelvis, or behind the caecum, the adhesion 
may take place in such a way that the perforation occurs into the retro- 
peritoneal tissue. In these days of operation we do not so often see the ex- 
tensive retro-peritoneal abscesses due to appendix disease. The pus may 
pass beneath the iliac fascia and appear at Poupart's ligament, in which 



APPENDICITIS. 



523 



situation external perforation may occur and recovery take place. The 
pus may be chiefly in the retro-peritoneal tissue in the flank, forming a 
large perinephritic abscess. In a case under the care of Gardner, of Mont- 
real, an enormous abscess cavity developed in this situation, which con- 
tained air, pushed up the diaphragm nearly to the second rib, and produced 
the symptoms of pneumothorax. Perforation of the pleura may occur in 
these cases, forming a faecal pleural fistula. The pus may extend along 
the psoas muscle and may perforate the hip joint, or pass to the neighbor- 
hood of the rectum, or produce multiple abscesses of the scrotum; or, pass- 
ing through the obturator foramen, form a large gluteal abscess. Both the 
intra- and extra-peritoneal appendix abscess may perforate into the bladder 
or into the bowel, and recovery may follow, though there is greater danger 
in perforation into the latter. The appendix has been discharged per 
anum. 

Remote Effects, — The remote effects of perforative appendicitis are in- 
teresting. Haemorrhage may occur. In one of my cases the appendix was 
adherent to the promontory of the sacrum, and the abscess cavity had per- 
forated in two places into the ileum. Death resulted from profuse haemor- 
rhage. Cases are on record in which the internal iliac artery or the deep 
circumflex iliac artery has been opened. Suppurative pylephlebitis may 
result from inflammation of the mesenteric veins near the perforated ap- 
pendix. Two instances of it have come under my notice; in one there 
was a small localized abscess which had resulted from the perforation of a 
typhoid ulcer of the appendix. In the other case, which I saw with Ma- 
chell, of Toronto, the symptoms were those of septicaemia and of suppura- 
tion of the liver. The abscess of the appendix was small and had not pro- 
duced symptoms. In the healing of extensive inflammation about the mar- 
gin of the pelvis the iliac veins may be greatly compressed, and one of my 
patients had for months oedema of the right leg, which is now permanently 
enlarged. 

The appendix may perforate in a hernial sac. Several instances of this 
have been recorded. In a case which came under my care at the Uni- 
versity Hospital, Philadelphia, there was a hernia of the caecum in the 
inguinal canal. The proximal orifice of the appendix was at the extreme 
end of the hernia in the inguinal canal. The tube then curved upon itself, 
passed into the abdomen, and the terminal three fourths of an inch had 
sloughed in a small circumscribed sac situated close to the promontory of 
the sacrum. 

The following additional facts may be mentioned, bearing on the eti- 
ology: 

Age. — Appendicitis is a disease of young persons. According to Fitz's 
statistics, more than 50 per cent of the cases occur before the twentieth 
year; according to Einhom's, 60 per cent between the sixteenth and thir- 
tieth years. It has been met with as early as the seventh week, but it is 
rarely seen prior to the third year. 

Sex. — It is much more common in males than in females, 80 per cent 
of the former in the table of Fitz. In Hawkins' series, 161 were maies 
and 63 females. Contrary to the general experience, the Munich figures 



524 



DISEASES OF THE DIGESTIVE SYSTEM. 



given by Einhorn indicate a relatively greater number of women at- 
tacked. 

Occupation — Persons whose work necessitates the lifting of heavy 
weights seem more prone to the disease. Trauma plays a very definite role, 
and in a number of cases the symptoms have followed very closely a fall or 
a blow. 

Indiscretions in diet are very prone to bring on an attack, particularly 
in the recurring form of the disease, in which pain in the appendix region 
not infrequently follows the eating of indigestible articles of food. I have 
been impressed, too, with the number of cases in boys in which there has 
been a history of gorging with peanuts. 

Symptoms, — In a large proportion of all cases of acute appendicitis 
the following symptoms are present: (1) Sudden pain in the abdomen, usu- 
ally referred to the right iliac fossa; (2) fever, often of moderate grade; 
(3) gastro-intestinal disturbance — nausea, vomiting, and frequently consti- 
pation; (4) tenderness or pain on pressure in the appendix region. 

Such a group of symptoms in a young person, particularly following an 
indiscretion in diet or an injury or strain, in the absence of signs of hernia, 
indicate the existence of appendicitis; they do not suggest in any way the 
nature of the lesion, whether obliterative, ulcerative, or an acute necrotic 
appendicitis. We may first consider more fully these general symptoms of 
the disease. 

Pain. — A sudden, violent pain in the abdomen is, according to Fitz, 
the most constant, first, decided symptom of perforating inflammation of 
the appendix, and occurred in 84 per cent of the cases analyzed by him. 
In fully half of the cases it is localized in the right iliac fossa, but 
it may be central, diffuse, or indeed in almost any region of the abdo- 
men. Even in the cases in which the pain is at first not in the appendix 
region, it is usually felt here within thirty-six or forty-eight hours. It 
may extend toward the perinaeum or testicle. It is sometimes very sharp 
and colic-like, and cases have been mistaken for nephritic or for biliary 
colic. Some patients speak of it as a sharp, intense pain — serous-mem- 
brane pain; others as a dull ache — connective-tissue pain. While a very 
valuable symptom, pain is at the same time one of the most misleading. 
Some of the forms of recurring pain in the appendix region Talamon 
has called appendicular colic. The condition is believed to be due to 
partial occlusion of the lumen, leading to violent and irregular peristal- 
tic action of the circular and longitudinal muscles in the expulsion of the 
mucus. 

Fever. — A rise in the temperature follows rapidly upon the pain, and is 
one of the most valuable of the symptoms of the early stage of appendi- 
citis. An initial chill is very rare. The fever may be moderate, from 
100° to 102°; sometimes in children at the very outset the - thermometer 
may register above 103.5°. The thermometer is one of the most trust- 
worthy guides in the diagnosis of acute appendicitis. Appendicular colic 
of great severity may occur without fever. When a localized abscess has 
formed, and in some very virulent cases of general peritonitis, the tempera- 
ture may be normal, but at this stage there are other symptoms which in- 



APPENDICITIS. 



525 



dicate the gravity of the situation. The pulse is quickened in proportion 
to the fever. 

Gastro-intestinal Disturbance. — The tongue is usually furred and moist, 
seldom dry. Nausea and vomiting are symptoms which may be absent, 
but which are commonly present in the acute perforative cases. The vom- 
iting rarely persists beyond the second day in favorable cases. Constipa- 
tion is the rule, but the attack may set in with diarrhoea, particularly in 
children. 

Local Signs. — Inspection of the abdomen is at first negative; there is no 
distention, and the iliac fossae look alike. On palpation there are usually 
from the outset two important signs — namely, great tension of the right 
rectus muscle, and tenderness or actual pain on deep pressure. The mus- 
cular rigidity may be so great that a satisfactory examination cannot be 
made without an anaesthetic. McBurney has called attention to the value 
of a localized point of tenderness on deep pressure, which is situated at the 
intersection of a line drawn from the navel to the anterior superior spine 
of the ilium, with a second, vertically placed, corresponding to the outer 
edge of the right rectus muscle. Firm, deep, continuous pressure with 
one finger at this spot causes pain, often of the most exquisite character. 
In addition to the tenderness, rigidity, and actual pain on deep pressure, 
there is to be felt, in a majority of the cases, an induration or swelling. 
In some cases this is a boggy, ill-defined mass in the situation of the 
caecum; more commonly the swelling is circumscribed and definite, situated 
in the iliac fossa, two or three fingers' breadth above Poupart's ligament. 
Some have been able to feel and roll beneath the fingers the thickened ap- 
pendix. The later the case comes under observation the greater the proba- 
bility of the existence of a well-marked tumor mass. It is not to be for- 
gotten that there may be neither tumor mass nor induration to be felt in 
some of the most intensely virulent cases of perforative appendicitis. 

In addition may be mentioned great irritability of the bladder, which 
I have known to lead to the diagnosis of cystitis. It may be a very early 
symptom. The urine is scanty and often contains albumin and indican. 
Peptonuria is of no moment. The attitude is somewhat suggestive, the 
decubitus is dorsal, and the right leg is semi-flexed. Examination per 
rectum in the early stages rarely gives any information of value, unless the 
appendix lies well over the brim of the pelvis, or unless there is a large 
abscess cavity. Severe cases usually show a leucocytosis of 15,000 to 24,000. 

There are three possibilities in any case of appendicitis presenting the 
above symptoms: (1) Gradual recovery, (2) the formation of a local abscess, 
and (3) the development of a general peritonitis. 

Recovery is the rule. Out of 264 cases at St. Thomas's Hospital with 
the above-mentioned clinical characters, 190 recovered. In one instance 
the appendix was removed, and in two, attempts were made to remove it 
(Hawkins). There are surgeons who claim that the getting well in these 
cases does not mean much; that the patients have recurrences and are con- 
stantly liable to the graver accidents of the disease. This, I feel sure, is 
an unduly dark picture. 

In a case which is proceeding to recoverv the pain lessens at the end of 



526 



DISEASES OF THE DIGESTIVE SYSTEM. 



the third or fourth day, the temperature falls, the tongue becomes cleaner, 
the vomiting ceases, the local tenderness is less marked, and the bowels 
are moved. By the end of a week the acnte symptoms have subsided. The 
entire attack may not last more than ten days. In other instances slight 
fever persists, and it may be two or three weeks before convalescence is 
established. An induration or an actual small tumor mass from the size 
of a walnut to that of an egg may persist — a condition which leaves the 
patients very liable to a recurrence. 

In these cases there is either a chronic appendicitis without perforation 
or involvement of the serous surface, or there is implication of the peri- 
toneal surface, usually from perforation, with a sero-fibrinous exudate 
and an agglutination of the contiguous parts. In the cases with a well- 
defined tumor, whether large or small, there is almost always pus forma- 
tion. 

Local Abscess Formation— As a result of ulceration and perforation, 
sometimes following the necrosis, rarely as a sequence of the diffuse ap- 
pendicitis, the patient has the train of symptoms above described; but at 
the end of the first week the local features persist or become aggravated. 
The course of the disease may be indeed so acute that by the end of the 
fourth or fifth day there is an extensive area of induration in the right 
iliac fossa, with great tenderness, and operations have shown that even at 
this very early date an abscess cavity may have formed. Though as a rule 
the fever becomes aggravated with the onset of suppuration, this is not 
always the case. The two most important elements in the diagnosis of 
abscess formation are the gradual increase of the local tumor and the aggra- 
vation of the general symptoms. Nowadays, when operation is so frequent, 
we have opportunities of seeing the abscess in various stages of develop- 
ment. Quite early the pus may lie between the caecum and the coils of 
the ileum, with the general peritonaeum shut off by fibrin, or there is a sero- 
fibrinous exudate with a slight amount of pus between the lower coils of the 
ileum. The abscess cavity may be small and lie on the psoas muscle, or 
at the edge of the promontory of the sacrum, and never reach a palpable 
size. The sac, when larger, may be roofed in by the small bowel and pre- 
sent irregular processes and pockets leading in different directions. In 
larger collections in the iliac fossa the roof is generally formed by the ab- 
dominal wall. Some of the most important of the localized abscesses are 
those which are situated entirely within the pelvis. The various directions 
and positions into which the abscess may pass or perforate have already 
been referred to under morbid anatomy, but it may be here mentioned 
again that, left alone, it may discharge externally, or burrow in various 
directions, or be emptied through the rectum, vagina, or bladder. Death 
may be caused by septicaemia, by perforation into an artery or vein, or by 
pylephlebitis. 

General Peritonitis.— This may be caused by direct perforation of the 
appendix and general infection of the peritonaeum before any delimiting 
inflammation is excited. In a second group of cases there has been an at- 
tempt at localizing the infective process, but it fails, and the general peri- 
tonaeum becomes involved. In a third group of cases a localized focus of 



APPENDICITIS. 



527 



suppuration exists about an inflamed appendix, and from this perforation 
takes place. 

Death in appendicitis is due usually to general peritonitis. 

We see at operations all grades of the affection, from the mildest, in 
which the serous surface is injected, turbid, and sticky, but without lymph 
or effusion, except in the immediate neighborhood of the perforated ap- 
pendix. In other cases there is a fibrinous exudate gluing the coils to- 
gether and a variable amount of turbid serous fluid. In other instances, 
as the abdomen is opened, pus wells out, and there is a diffuse purulent in- 
flammation of the peritonaeum. It is interesting, however, to note the com- 
parative rarity of fatal peritonitis from appendix disease in general medical 
work. In 450 consecutive autopsies on patients dead in my wards there 
was not a single instance of general peritonitis from appendix disease. On 
the surgical side there have been admitted during the same period 10 cases 
of diffuse peritonitis from this cause. Eight were operated upon; all died. 
In 9 cases there was found a perforated and more or less gangrenous ap- 
pendix, with little or no attempt at localization; in 1 case rupture of 
an abscess caused the general peritonitis. 

The gravity of appendix disease lies in the fact that from the very outset 
the peritonaeum may be infected; the initial symptoms of pain, with nausea 
and vomiting, fever, and local tenderness, present in all cases, may indicate a 
widespread infection of this membrane. The onset is usually sudden, the 
pain diffuse, not always localized in the right iliac fossa, but it is not so 
much the character as the greater intensity of the symptoms from the out- 
set that makes one suspicious of a general peritonitis. Abdominal disten- 
tion, diffuse tenderness, and absence of abdominal movements are the most 
trustworthy local signs, but they are not really so trustworthy as the gen- 
eral symptoms. The initial nausea and vomiting persist, the pulse be- 
comes more rapid, the tongue is dry, the urine scanty. In very acute 
cases, by the end of twenty-four hours the abdomen may be distended. By 
the third and fourth clays the classical picture of a general peritonitis is 
well established — a distended and motionless abdomen, a rapid pulse, a dry 
tongue, dorsal decubitus with the knees drawn up, and an anxious, pinched, 
Hippocratic facies. Unfortunately, the leucocyte count gives little aid. 

Fever is an uncertain element. It is usually present at first, but if the 
physician does not see the case until the third or fourth day he should 
not be deceived by a temperature below 100.5°. The pulse is really a 
better indication than the temperature. One rarely has any doubt on the 
third or fourth day whether or not peritonitis exists, but it must be ac- 
knowledged that there are exceptions which trouble the judgment not a 
little. While on the one hand, without suggestive symptoms, a laparotomy 
has disclosed an unexpected general peritonitis, on the other, with severe 
constitutional symptoms and apparently characteristic local -signs, the peri- 
tonaeum has been found smooth. 

Relapsing Appendicitis.— Pepper, in 1883, called attention to the re- 
markable liability to relapse in perityphlitis. The patient gets well and 
all trace of induration and tenderness disappears; then in three or four 
months, or earlier, he again has fever, pain, and local signs of trouble. 
33 



528 



DISEASES OF THE DIGESTIVE SYSTEM. 



The attacks may recur for years. The cases which recover with the per- 
sistence of an induration or tumor mass are most prone to relapse. There 
are more severe cases in which the intervals between the attacks are very 
short, and the patient becomes a chronic invalid. After repeated attacks, 
however, recovery may be perfect. The frequency of recurrence is difficult 
to estimate. Fitz places it at 44 per cent, Hawkins at 23.6 per cent. The 
recent statistics of operations given by Deaver, Murphy, and others indi- 
cate how common must be this type of the disease. Bull has collected 
442 operations in chronic relapsing appendicitis by eighty surgeons, with 
a mortality of 1.8 per cent, but he thinks that 5 or 6 per cent would be a 
fairer estimate. 

The morbid condition in this form is either a simple obliterative ap- 
pendicitis with or without adhesions, or an adherent, perhaps perforated 
appendix with a small localized abscess circumscribed by dense fibroid 
tissue. 

Diagnosis. — Appendicitis is by far the most common inflammatory 
condition, not only in the csecal region, but in the abdomen generally in 
persons under thirty. The surgeons have taught us that, almost without 
exception, sudden pain in the right iliac fossa, with fever and localized ten- 
derness, with or without tumor, means appendix disease. There are cer- 
tain diseases of the abdominal organs characterized by pain which are apt 
to be confounded with appendicitis. Biliary colic, kidney colic, and the 
colicky pains at the menstrual period in women have in some cases to be 
most carefully considered. I have not met with an instance of either renal 
or hepatic calculus causing any difficulty in diagnosis, but a patient was 
admitted to my wards with a history of very sudden onset of severe pain 
three days previously in the right side of the abdomen, and with an ill- 
defined tumor mass low in the right flank. Fortunately, she was trans- 
ferred at once to the surgical side for operation, and the condition proved 
to be an acutely distended and inflamed gall-bladder almost on the point 
of perforating. A second very similar case has since occurred. 

Diseases of the tubes and pelvic peritonitis may simulate appendicitis 
very closely, but the history and the local examination under ether should 
in most cases enable the practitioner to reach a diagnosis. I have seen 
several cases supposed to be recurring appendicitis which proved to be tubo- 
ovarian disease. 

The Dietl's crises in floating kidney have been mistaken for appendi- 
citis. 

Both intussusception and internal strangulation may present very sim- 
ilar symptoms, and if the patient is only seen at the later stages, when 
there is diffuse peritonitis and great tympany, the features may be almost 
identical. Fsecal vomiting, which is common in obstruction, is never seen 
in appendicitis, and in children the marked tenesmus and bloody stools 
are important signs of intussusception. It is not often difficult to decide 
when the cases are seen early and when the history is clear, but mistakes 
have been made by surgeons of the first rank. 

Acute hemorrhagic pancreatitis may also produce symptoms very like 
those of appendicitis with general peritonitis. The relation of typhoid 



APPENDICITIS. 



529 



fever and appendicitis is interesting. The gastro-intestinal symptoms, par- 
ticularly the pain and the fever, may at the onset suggest appendicitis. 
Operations have heen comparatively frequent. Dr. Bloodgood tells me that 
two cases have been admitted to the Johns Hopkins Hospital and have 
been operated upon as acute appendicitis, and subsequently the diagnosis 
of typhoid has been made. In the second and third weeks of typhoid fever 
perforation of the appendix may occur, and occasionally late in the con- 
valescence perforation of an unhealed ulcer of the appendix. 

There is a well-marked appendicular hypochondriasis. Through the 
pernicious influence of the daily press, appendicitis has become a sort of 
fad, and the physician has often to deal with patients who have almost 
a fixed idea that they have the disease. The worst cases of this class 
which I have seen have been in members of our profession, and I know of 
at least one instance in which a perfectly normal appendix was removed. 
The question really has its ludicrous side. A well-known physician in a 
Western city having one night a bellyache, and feeling convinced that his 
appendix had perforated, summoned a surgeon, who quickly removed the 
supposed offender! 

Hysteria may of course simulate appendicitis very closely, and it may 
require a very keen judgment to make a diagnosis. 

Mucous colitis with enteralgia in nervous women is sometimes mis- 
taken for appendicitis. In two instances of the kind I have prevented 
proposed operation, and I have heard of cases in which the appendix has 
been removed. 

Perinephritic and pericecal abscess from perforation of ulcer, either 
simple or cancerous, and circumscribed peritonitis in this region from other 
causes, can rarely be differentiated until an exploratory incision is made. 

Chronic obliterative appendicitis cannot always be differentiated from 
the perforative form, and in intensity of pain, severity of symptoms, and, in 
rare instances, even in the production of peritonitis, the two may be iden- 
tical. 

Briefly stated, localized pain in the right iliac fossa, with or without 
induration or tumor, the existence of McBurney's tender point, fever, 
furred tongue, vomiting, with constipation or diarrhoea, indicate appendi- 
citis. The occurrence of general peritonitis is suggested by increase and 
diffusion of the abdominal pain, tympanites (as a rule), marked aggrava- 
tion of the constitutional symptoms, particularly elevation of fever and in- 
creased rapidity of the pulse. Obliteration of hepatic dulness is rarely 
present, as the peritonaeum in these cases does not often contain gas. 

Prognosis. — While we cannot overestimate the gravity of certain 
forms of appendicitis, it is well to recognize that a large proportion of all 
cases recover. It is the element of uncertainty in individual cases which 
has given such an impetus to the surgical treatment of the disease. That 
an inflamed appendix may heal perfectly, even after perforation, is shown 
by instances (post mortem) of obliterated tubes firmly imbedded in old 
scar tissue. Formerly we had not a full knowledge of the natural history of 
the disease, As J. William White remarked in an address at the College 
of Physicians, Philadelphia, " We are in special need of reliable medical 



530 



DISEASES OF THE DIGESTIVE SYSTEM. 



statistics as to this point." These have now been supplied in the admi- 
rable monograph of Hawkins (London, 1895), in which he has analyzed the 
cases at St. Thomas's Hospital, 264 in number. The work is to be com- 
mended particularly to surgeons, since, while written from the standpoint 
of the physician and pathologist, the author is fully alive to the surgical 
aspects of the disease, and does ample justice to the work of American 
operators. His figures are as follows: (a) Peritonitis, limited to the right 
iliac fossa and not proceeding to the formation of pus, 190 cases, no 
deaths; (b peritonitis, similarly localized, but ending in the formation 
of pus (perityphlitic abscess), 38 cases, with 10 deaths; (c) general peri- 
tonitis, 36 cases, with 27 deaths. This gives a total mortality of 14 per 
cent. Fifty-nine of the 264 patients had had one or more previous at- 
tacks; 45 of these had simple " perityphlitis," and all recovered; of 7 with 
abscess formation, 3 died; of 7 with general peritonitis, 3 died. These fig- 
ures compare very favorably with those collected by Porter: Eemovcl of 
appendix duping the attack, 19.7 per cent mortality; incision and drain- 
age of abscess, 18.18 per cent of deaths. The statistics of individual opera- 
tors give a much more favorable showing, and we may say that in acute 
cases without generalized peritonitis, and in the localized appendicular ab- 
scess, the percentage of deaths in the hands of good surgeons is now very 
much lower. 

. Treatment. — So impressed am I by the fact that we physicians lose 
lives by temporizing with certain cases of appendicitis, that I prefer, in 
hospital work, to have the suspected cases admitted directly to the surgical 
side. The general practitioner does well to remember — whether his lean- 
ings be toward the conservative or the radical methods of treatment — that 
the surgeon is often called too late, never too early. 

There is no medicinal treatment of appendicitis. There are remedies 
which will allay the pain, but there are none capable in any way of con- 
trolling the course of the disease. Eest in bed, a light diet, measures di- 
rected to allay the vomiting — upon these all are agreed. There are two 
points on which the profession is very much divided, namely, the use of 
opium and of saline purges. The practice of giving opium in some form 
in appendicitis and peritonitis is almost universal with physicians. Sur- 
geons, on the other hand, almost unanimously condemn the practice, as 
obscuring the clinical picture and tending to give a false sense of security; 
and since they control the situation, I think we should — deferring in this 
matter to their judgment — give less opium, and trust to the persistent use 
of ice locally to relieve the pain. 

The use of saline purges early in the disease, which is advocated by 
some surgeons, is, I believe, a most injurious practice. In any given case 
the pain and tenderness at the outset may mean perforation of the appen- 
dix, and the life of the patient may depend upon whether a limiting adhe- 
sive inflammation is set up. Under these circumstances, anything that 
will stimulate active peristalsis of the bowel wall throughout its extent is 
certainlv contra-indicated. Surgery, too, has taught us that the csecum is 
rarely, if ever, filled with hardened fagces, so that it is really on, theoretical 
grounds that a saline is urged to clear this part of the bowel. I am glad 



INTESTINAL OBSTRUCTION. 



531 



to see, too, that some surgeons of the largest experience, as McBurney, 
state that they never employ purgatives. They are also contra-indicated, I 
think, when there are signs of the formation of a local abscess. If useful 
at all, it is when general peritonitis has been established, but then, as a 
rule, the mischief is done, and purgatives cannot influence the result. 

Operation is indicated in all cases of acute inflammatory trouble in the 
csecal region, whether tumor is present or not, when the general symptoms 
are severe, and when by the third day the features of the case point to a pro- 
gressive lesion. The mortality from early operation under these circum- 
stances is very slight. 

In recurring appendicitis, when the attacks are of such severity and 
frequency as seriously to interrupt the patient's occupation, the figures al- 
ready given show how slight the mortality is in the hands of capable oper- 
ators. Unfortunately, in hospital practice too many cases are brought in 
with general peritonitis — a condition in which operation is rarely successful. 

Post-operative Features in Appendicitis. — Unfortunately, the operation 
does not always finish the victim's troubles. I have been consulted by sev- 
eral patients with severe pain following the operation, and the literature con- 
tains a number of reports of recurrence of the pain in the right iliac fossa. 
There have been instances, indeed, in which an indurated cord has been 
felt, and might have readily been mistaken for the appendix had it not been 
previously removed. In some instances a second operation has been suc- 
cessful in freeing the adhesions which have caused the pain. 



III. INTESTINAL OBSTRUCTION. 

Intestinal obstruction may be caused by strangulation, intussusception, 
twists and knots/ strictures and tumors, and by abnormal contents. 

Etiology and Pathology.— (a) Strangulation —This is the most 
frequent cause of acute obstruction, and occurred in 34 per cent of the 295 
cases analyzed by Fitz,* and in 35 per cent of the 1,134 cases of Leichten- 
stern.f Of the 101 cases of strangulation in Fitz's table, which has the spe- 
cial value of having been carefully 'selected from the literature since 1880, 
the following were the causes: Adhesions, 63; vitelline remains, 21; adher- 
ent appendix, 6; mesenteric and omental slits, 6; peritoneal pouches and 
openings, 3; adherent tube, 1; peduncular tumor, 1. The bands and adhe- 
rens result, in a majority of cases, from former peritonitis. A number 
of instances have been reported following operations upon the pelvic or- 
gans in women. The strangulation may be recent and due to adhesion of 
the bowel to the abdominal wound or a coil may be caught between the 
pedicle of a tumor and the pelvic wall. Such cases are only too common. 
Late (.(elusion after recovery from the operation is due to bands and ad- 
hesions. 



* Transactions of the Congress of American Physicians and Surgeons, vol. i, 1889. 
The percentages of his tables are used throughout this section, 
f Yon Ziemssen's Encyclopaedia of Practical Medicine. 



532 



DISEASES OF THE DIGESTIVE SYSTEM. 



The vitelline remains are represented by Meckel's diverticulum, which 
forms a finger-like projection from the ileum, usually within eighteen 
inches of the ileo-caBcal valve. It is a remnant of the omphalo-mesenteric 
duct, through which, in the early embryo, the intestine communicated with 
the yolk-sac. The end, though commonly free, may be attached to the 
abdominal wall near the navel, or to the mesentery, and a ring is thus 
formed through which the gut may pass. 

Seventy per cent of the cases of obstruction from strangulation occur 
in males; 40 per cent of all the cases occur between the ages of fifteen and 
thirty years. In 90 per cent of the cases of obstruction from these causes 
the site of the trouble is in the small bowel; the position of the strangulated 
portion was in the right iliac fossa in 67 per cent of the cases, and in the 
lower abdomen in 83 per cent. 

(&) Intussusception. — In this condition one portion of the intestine slips 
into an adjacent portion, forming an invagination or intussusception. The 
two portions make a cylindrical tumor, which varies in length from a half- 
inch to a foot or more. The condition is always a descending intussuscep- 
tion, and as the process proceeds, the middle and inner layers increase at 
the expense of the outer layer. An intussusception consists of three layers 
of bowel: the outermost, known as the intussuscipiens, or receiving layer; 
a middle or returning layer; and the innermost or entering layer. The 
student can obtain a clear idea of the arrangement by making the end of a 
glove-finger pass into the lower portion. The actual condition can be very 
clearly studied in the post-mortem invaginations which are so common in 
the small bowel of children. In the statistics of Fitz, 93 of 295 cases 
of acute intestinal obstruction were due to this cause. Of these, 52 were in 
males and 27 in females. The cases are most common in early life, 34 
per cent under one year and 56 per cent under the tenth year. Of 103 
cases in children, nearly 50 per cent occurred in the fourth, fifth, and sixth 
months (Wiggin). No definite causes could be assigned in 42 of the cases; 
in the others diarrhoea or habitual constipation had existed. 

The site of the invagination varies. We may recognize (1) an ileo-ccccal, 
when the ileo-CBecal valve descends into the colon. There are cases in 
which this is so extensive that the valve has been felt per rectum. This 
form occurred in 75 per cent of the cases; in 89 per cent of Wiggings col- 
lected cases. In the ileo-colic the lower part of the ileum passes through 
the ileo-csecal valve. (2) The ileal, in which the ileum is alone involved. 
(3) The colic, in which it is confined to the large intestine. And (4) colico- 
rectal, in which the colon and rectum are involved. 

Irregular peristalsis is the essential cause of intussusception. Noth- 
nagel found in the localized peristalsis caused by the faradic current that 
it was not the descent of one portion into the other, but the drawing up 
of the receiving layer by contraction of the longitudinal coat. Invagina- 
tion may follow any limited, sudden, and severe peristalsis. 

In the post-mortem examination, in a case of death from intussuscep- 
tion, the condition is very characteristic. Peritonitis may be present or 
an acute injection of the serous membrane. When death occurs early, as 
it may do from shock, there is little to be seen. The portion of bowel 



INTESTINAL OBSTRUCTION. 



533 



affected is large and thick, and forms an elongated tumor with a curved 
outline. The parts are swollen and congested, owing to the constriction 
of the mesentery between the layers. The entire mass may be of a 
deep livid-red color. In very recent processes there is only congestion, and 
perhaps a thin layer of lymph, and the intussusception can be reduced, 
but when it has lasted for a few days, lymph is thrown out, the layers 
are glued together, and the entering portion of the gut cannot be with- 
drawn. 

The anatomical condition accounts for the presence of the tumor, which 
exists in two thirds of all cases; and the engorgement, which results from 
the compression of the mesenteric vessels, explains the frequent occurrence 
of blood in the discharges, which has so important a diagnostic value. If 
the patient survives, necrosis and sloughing of the invaginated portion may 
occur, and if union has taken place between the middle and outer layer, 
the calibre of the gut may be restored and a cure in this way effected. 
Many cases of the kind are on record. In the Museum of the Medical Fac- 
ulty of McGill University are 17 inches of small intestine, which were 
passed by a lad who had had symptoms of internal strangulation, and who 
made a complete recovery. 

(c) Twists and Knots. — Volvulus or twist occurred in 42 of the 295 
cases. Sixty-eight per cent were in males. It is most frequent between 
the ages of thirty and forty. In the great majority of all cases the twist 
is axial and associated with an unusually long mesentery. In 50 per cent 
of the cases it was in the sigmoid flexure. The next most common situa- 
tion is about the caecum, which may be twisted upon its axis or bent upon 
itself. As a rule, in volvulus the loop of bowel is simply twisted upon its 
long axis, and the portions at the end of the loop cross each other and so 
cause the strangulation. It occasionally happens that one portion of the 
bowel is twisted about another. 

(d) Strictures and Tumors. — These are very much less important causes 
of acute obstruction, as may be judged by the fact that there are only 15 
instances out of the 295 cases, in 14 of which the obstruction occurred in 
the large intestine. On the other hand, they are common causes of chronic 
obstruction. 

The obstruction may result from: (1) Congenital stricture. These are 
exceedingly rare. Much more commonly the condition is that of complete 
occlusion, either forming the imperforate anus or the congenital defect by 
which the duodenum is not united to the pylorus. (2) Simple cicatricial 
stenosis, which results from ulceration, tuberculous or syphilitic, more 
rarely from dysentery, and most rarely of all from typhoid ulceration. (3) 
New growths. The malignant strictures are due chiefly to cylindrical epi- 
thelioma, which forms an annular tumor, most commonly met with in the 
fargc bowel, about the sigmoid flexure, or the descending colon. Of be- 
nign growths, papillomata, adenomata, lipomata, and fibromata occasion- 
ally induce obstruction. (4) Compression and traction. Tumors of neigh- 
boring organs, particularly of the pelvic viscera, may c;iuse obstruction by 
adhesion and traction; more rarely, a coil, such as the sigmoid flexure, 
filled with faeces, compresses and obstructs a neighboring coil. In the heal- 



534 



DISEASES OF THE DIGESTIVE SYSTEM, 



ing of tuberculous peritonitis the contraction of the thick exudate may 
cause compression and narrowing of the coils. 

(e) Abnormal Contents. — Foreign bodies, such as fruit stones, coins, pins, 
needles, or false teeth, are occasionally swallowed accidentally, or by luna- 
tics on purpose. Bound worms may become rolled into a tangled mass 
and cause obstruction. In reality, however, the majority of foreign bodies, 
such as coins, buttons, and pins, swallowed by children, cause no incon- 
venience whatever, but in a day or two are found in the stools. Occasion- 
ally such a foreign body as a pin will pass through the oesophagus and will 
be found lodged in some adjacent organ, as in the heart (Peabody), or a 
barley ear may reach the liver (Dock). 

Medicines, such as magnesia or bismuth, have been known to accumu- 
late in the bowels and produce obstruction, but in the great majority of 
the cases the condition is caused by faeces, gall-stones, or enteroliths. Of 
44 cases, in 23 the obstruction was by gall-stones, in 19 by fasces, and in 2 
by enteroliths. Obstruction by faeces may happen at any period of life. 
As mentioned when speaking of dilatation of the colon, it may occur in 
young children and persist for weeks. In faecal accumulation the large 
bowel may reach an enormous size and the contents become very hard. 
The retained masses may be channeled, and small quantities of f aecal matter 
are passed until a mass too large enters the lumen and causes obstruction. 
There may be very few symptoms, as the condition may be borne for weeks 
or even for months. 

Obstruction by gall-stones is not very infrequent, as may be gathered 
from the fact that 23 cases were reported in the literature in eight years. 
Eighteen of these were in women and 5 in men. In six sevenths of the 
cases it occurred after the fiftieth year. The obstruction is usually in the 
ileo-caecal region, but it may be in the duodenum. These large solitary 
gall-stones ulcerate through the gall-bladder, usually into the small intes- 
tine, occasionally into the colon. In the latter case they rarely cause ob- 
struction Courvoisier has collected 131 cases in the literature. 

Enteroliths may be formed of masses of hair, more commonly of the 
phosphates of lime and magnesia, with a nucleus formed of a foreign body 
or of hardened faeces. Nearly every museum possesses specimens of this 
kind. They are not so common in men as in ruminants, and, as indicated 
in Fitz's statistics, are very rare causes of obstruction. 

Symptoms. — (a) Acute Obstruction. — Constipation, pain in the abdo- 
men, and vomiting are the three important symptoms. Pain sets in early 
and may come on abruptly while the patient is walking or, more com- 
monly, during the performance of some action. It is at first colicky in 
character, but subsequently it becomes continuous and very intense. Vom- 
iting follows quickly and is a constant and most distressing symptom. At 
first the contents of the stomach are voided, and then greenish, bile- 
stained material, and soon, in cases of acute and permanent obstruction, 
the material vomited is a brownish-black liquid, with a distinctly faecal 
odor. This sequence of gastric, bilious, and, finally, stercoraceous vomit- 
ing is perhaps the most important diagnostic feature of acute obstruction. 
The constipation may be absolute, without the discharge of either faeces 



INTESTINAL OBSTRUCTION. 



535 



or gas. Very often the contents of the bowel below the stricture are dis- 
charged. Distention of the abdomen usually occurs, and when the large 
bowel is involved it is extreme. On the other hand, if the obstruction is 
high up in the small intestine, there may be very slight tympany. At 
first the abdomen is not painful, but subsequently it may become acutely 
tender. 

The constitutional symptoms from the outset are severe. The face is 
pallid and anxious, and finally collapse symptoms supervene. The eyes 
become sunken, the features pinched, and the skin is covered with a cold, 
clammy sweat. The pulse becomes rapid and feeble. There may be no 
fever; the axillary temperature is often subnormal. The tongue is dry 
and parched and the thirst is incessant. The urine is high-colored, scanty, 
and there may be suppression, particularly when the obstruction is high 
up in the bowel. This is probably due to the constant vomiting and the 
small amount of liquid which is absorbed. The case terminates as a rule 
in from three to six days. In some instances the patient dies from shock 
or sinks into coma. A leucocytosis of 75,000 or 80,000 per c. mm. may be 
present. 

(b) Symptoms of Chronic Obstruction. — When due to faecal impaction, 
there is a history of long-standing constipation. There may have been 
discharge of mucus, or in some instances the faecal masses have been chan- 
neled, and so have allowed the contents of the upper portion of the bowel 
to pass through. In elderly persons this is not infrequent; but examina- 
tion, either per rectum or externally, in the course of the colon, will reveal 
the presence of hard scybalous masses. There may be retention of faeces 
for weeks without exciting serious symptoms. In other instances there are 
vomiting, pain in the abdomen, gradual distention, and finally the ejecta 
become faecal. The hardened masses may excite an intense colitis or even 
peritonitis. 

In stricture, whether cicatricial or cancerous, the symptoms of obstruc- 
tion are very diverse. Constipation gradually comes on, is extremely vari- 
able, and it may be months or even years before there is complete obstruc- 
tion. There are transient attacks, in which from some cause the faeces 
accumulate above the stricture, the intestine becomes greatly distended, 
and in the swollen abdomen the coils can be seen in active peristalsis. In 
such attacks there may be vomiting, but it is very rarely of a faecal charac- 
ter. In the majority of these cases the general health is seriously im- 
paired; the patient gradually becomes anaemic and emaciated, and finally, 
in an attack in which the obstruction is complete, death occurs with all 
the features of acute occlusion or the case may be prolonged for ten or 
twelve days. 

Diagnosis.— (a) The Situation of the Obstruction.— Hernia must 
be excluded, which is by no means always easy, as fatal obstruction may 
occur from the involvement of a very limited portion of the gut in the 
external ring or in the obturator foramen. Mistakes from both of these 
causes have eomo under my observation; they were cases in which it was 
impossible to make a diagnosis other than acute obstruction. Timely op- 
eration would have saved both lives. A thorough rectal and, in women, a 
vaginal examination should be made, which will give important information 



536 



DISEASES OF THE DIGESTIVE SYSTEM. 



as to the condition of the pelvic and rectal contents, particularly in cases of 
intussusception, in which the descending bowel can sometimes be felt. In 
cases of obstruction high up the empty coils sink into the pelvis and can 
there be detected. Eectal exploration with the entire hand is of doubtful 
value. In the inspection of the abdomen there are important indications, as 
the special prominence in certain regions, the occurrence of indefinite, well- 
defined masses, and the presence of hypertrophied coils in active peristalsis. 
John Wyllie has recently called attention to the great value in diagnosis of 
the " patterns of abdominal tumidity." * In obstruction of the loAvcr end 
of the large intestine not only may the horseshoe of the colon stand out 
plainly, when the bowel is in rigid spasm, but even the pouches of the gut 
may be seen. When the caecum or lower end of the ileum is obstructed 
the tumidity is in the lower central region, and during spasm the coils of 
the small bowel may stand out prominently, one above the other, either 
obliquely or transversely placed — the so-called " ladder pattern." In ob- 
struction of the duodenum or jejunum there may only be slight distention 
of the upper part of the abdomen, associated usually with rapid collapse 
and anuria. 

In the ileum and caecum the distention is more in the central portion 
of the abdomen; the vomiting is distinctly faecal and occurs early. In 
obstruction of the colon, tympanites is much more extensive and general. 
Tenesmus is more common, with the passage of mucus and blood. The 
course is not so quick, the collapse does not supervene so rapidly, and the 
urinary secretion is not so much reduced. 

In obstruction from stricture or tumor the situation can in some cases 
be accurately localized, but in others it is very uncertain. Digital examina- 
tion of the rectum should first be made. The rectal tube may then be 
passed, but it is impossible to get beyond the sigmoid flexure. In the use 
of the rigid tube there is danger of perforation of the bowel in the neigh- 
borhood of a stricture. The quantity of fluid which can be passed into 
the large intestine should be estimated. The capacity of the large bowel is 
about six quarts. Wiggin advises about a pint and a half from a height of 
three feet for an infant. To thoroughly irrigate the bowel the patient 
should be chloroformed and should lie on the back or on the side — best on 
the back, with the hips elevated. Treves suggests that the eaecal region 
should be auscultated during the passage of the fluid. For diagnostic pur- 
poses the rectum may be inflated, either by the bellows or by the use of 
bicarbonate of soda and tartaric acid. In certain cases these measures give 
important indications as to the situation of the obstruction in the large 
bowel. 

(b) Nature of the Obstruction. — This is often difficult, not infrequently 
impossible, to determine. Strangulation is not common in very early life. 
In many instances there have been previous attacks of abdominal pain, or 
there are etiological factors which give a clew, such as old peritonitis or 
operation on the pelvic viscera. Neither the onset nor the character of the 
pain gives us any information. In rare instances nausea and vomiting 



* Edinburgh Hospital Reports, vol. ii. 



INTESTINAL OBSTRUCTION. 



537 



may be absent. The vomiting usually becomes faecal from the third to the 
fifth day. A tumor is not common in strangulation, and was present in 
only one fifth of the cases. Fever is not of diagnostic value. 

Intussusception is an affection of childhood, and is of all forms of in- 
ternal obstruction the one most readily diagnosed. The presence of tumor, 
bloody stools, and tenesmus are the important factors. The tumor is 
usually sausage-shaped and felt in the region of the transverse colon. It 
existed in 66 of 93 cases. It was present on the first day in more than one 
third of the cases, on the second day in more than one fourth, and on the 
third day in more than one fifth. Blood in the stools occurs in at least 
three fifths of the cases, either spontaneously or following the use of an 
enema. The blood may be mixed with mucus. Tenesmus is present in 
one third of the cases. Faecal vomiting is not very common and was pres- 
ent in only 12 of the 93 instances. Abdominal tympany is a symptom of 
slight importance, occurring in only one third of the cases. 

Volvulus can rarely be diagnosed. The frequency with which it in- 
volves the sigmoid flexure is to be borne in mind. The passage of a flex- 
ible tube or injecting fluids might in these cases give valuable indica- 
tions. An absolute diagnosis can probably be made only by an abdominal 
section. 

In f cecal obstruction the condition is usually clear, as the faeces can be 
felt per rectum and also in the distended colon. Faecal vomiting, tym- 
pany, abdominal pain, nausea, and vomiting are late and are not so con- 
stant. In obstruction by gall-stone a few of the cases gave a previous his- 
tory of gall-stone colic. Jaundice was present in only 2 of the 23 cases. 
Pain and vomiting, as a rule, occur early and are severe, and faecal vomit- 
ing is present in two thirds of the cases. A tumor is rarely evident. 

(c) Diagnosis from other Conditions. — Acute enteritis with great re- 
laxation of the intestinal coils, vomiting, and pain may be mistaken for 
obstruction. In an autopsy on a case of this kind the small and large 
bowels were intensely inflamed, relaxed, sodden, and enormously distended. 
The symptoms were those of acute obstruction, but the intestine was free 
from duodenum to rectum. Of late years many instances have been re- 
ported in which peritonitis following disease of the appendix has been 
mistaken for acute obstruction. The intense vomiting, the general tym- 
pany and abdominal tenderness, and in some instances the suddenness of 
the onset are very deceptive, and in two cases which have come under my 
notice the symptoms pointed very strongly to internal strangulation. In 
appendix disease the temperature is more frequently elevated, the vomit- 
ing is never faecal, and in many cases there is a history of previous attacks 
in the caecal region. Acute haemorrhagic pancreatitis may produce symp- 
toms which simulate closely intestinal obstruction. A boy was admitted 
to the Johns Hopkins Hospital with a history of obstinate vomiting, in- 
tense abdominal pain, gradually increasing tympany, and no passage for 
several days. His condition seemed serious and he was transferred at once 
to the surgical wards. At the operation the coils wore found uniformly 
(list cTidcd and covered in places with the thinnest film of lymph. No ob- 
struction existed, but there was a tumor-like mass surrounding the pan- 



538 



DISEASES OF THE DIGESTIVE SYSTEM. 



creas, firm, hard, and deeply infiltrated with blood. The patient improved 
after the operation and recovered completely. 

Treatment. — Purgatives should not be given. For the pain hypo- 
dermic injections of morphia are indicated. To allay the distressing vomit- 
ing, the stomach should be washed out. Not only is this directly beneficial, 
but Kussmaul claims that the abdominal distention is relieved, the pres- 
sure in the bowel above the seat of obstruction is lessened, and the violent 
peristalsis is diminished. It may be practised three or four times a day, 
and in some instances has proved beneficial; in others curative. Thor- 
ough irrigation of the large bowel with injections should be practised, the 
warm fluid being allowed to flow in from a fountain syringe, and the 
amount carefully estimated. Jonathan Hutchinson recommends that the 
patient be placed under an anaesthetic, the abdomen thoroughly kneaded, 
and a copious enema given while in the inverted position. Then, with the 
aid of three or four strong men, the patient is to be thoroughly shaken, 
first with the abdomen held downward, and subsequently in the inverted 
position. 

Inflation may also be tried, by forcing the air into the rectum with the 
bellows or with a Davidson's syringe. It is a measure not without risk, 
as instances of rupture of the bowel have been reported. Fitz's figures 
show that in the first eight years of the last decade there were 33 cases of 
recovery after injection or inflation in cases of certain or probable intussus- 
ception, and 11 deaths. Of 39 cases in children treated by inflation or ene- 
mata 16 recovered (Wiggin). In cases of acute obstruction, if these means 
do not prove successful by the third day, surgical measures should be re- 
sorted to, and when the obstruction seems persistent and the condition 
serious, laparotomy should be performed at once. Of 64 cases in which 
laparotomy was performed, 21 recovered. The youngest case operated upon 
was only three days old. 

For the tympanites turpentine stupes and hot applications may be ap- 
plied; if extreme, the bowel may be punctured with a small aspirator needle. 
In cases of chronic obstruction the diet must be carefully regulated, and 
opium and belladonna are useful for the paroxysmal pains. Enemata 
should be employed, and if the obstruction becomes complete, resort must 
be hadvto surgical measures. 



IV. CONSTIPATION (Costiveness). 

Definition. — Eetention of faeces from any cause. 
Constipation in Adults. — The causes are varied and may be classed as 
general and local. 

General Causes. — (a) Constitutional peculiarities: Torpidity of the 
bowels is often a family complaint and is found more often in dark than 
in fair persons, (b) Sedentary habits, particularly in persons who eat too 
much and neglect the calls of nature, (c) Certain diseases, such as anae- 
mia, neurasthenia and hysteria, chronic affections of the liver, stomach, 
and intestines, and the acute fevers. Under this heading may appropri- 



CONSTIPATION. 



539 



ately be placed that most injurious of all habits, drug-taking, (d) Either 
a coarse diet, which leaves too much residue, or a diet which leaves too 
little, may be a cause of costiveness. 

Local Causes. — Weakness of the abdominal muscles in obesity or from 
overdistention in repeated pregnancies. Atony of the large bowel from 
chronic disease of the mucosa; the presence of tumors, physiological or 
pathological, pressing upon the bowel; enteritis; foreign bodies, large 
masses of scybala, and strictures of all kinds. An important local cause 
is atony of the colon, particularly of the muscles of the sigmoid flexure by 
which the faeces are propelled into the rectum. By far the most obstinate 
form is that associated with a contracted state of the bowel, which is 
sometimes spoken of as spasmodic constipation. This may be met with 
in three conditions: First, as a sequence of chronic dysentery or ulcerative 
colitis; secondly, in protracted cases of hysteria and neurasthenia in women, 
particularly in association with uterine disease; and, thirdly, in very old 
persons often without any definite cause. It may be that the sigmoid 
flexure and lower colon are in a condition of contraction and spasm, while 
the transverse and ascending parts are in a state of atony and dilatation. 
The most characteristic sign of this variety is the presence of hard, globular 
masses, or more rarely small and sausage-like faeces. 

Symptoms. — The most persistent constipation for weeks or even 
months may exist with fair health. All kinds of evils have been attributed 
to poisoning by the resorption of noxious matters from the retained faeces 
— copraemia — but it is not likely that this takes place to any extent. Chlo- 
rosis, which Sir Andrew Clark attributes to faecal poisoning, is not always 
associated with constipation, and if due to this cause should be in men, 
women, and children the most common of all disorders. Debility, lassi- 
tude, and a mental depression are frequent symptoms in constipation, 
particularly in persons of a nervous temperament. Headache, loss of appe- 
tite, and a furred tongue may also occur. Individuals differ extraordina- 
rily in this matter: one feels wretched all day without the accustomed 
evacuation; another is comfortable all the week except on the day on 
which by purge or enema the bowels are relieved. 

When persistent, the accumulation of faeces leads to unpleasant, some- 
times serious symptoms, such as piles, ulceration of the colon, distention 
of the sacculi, perforation, enteritis, and occlusion. In women, pressure 
may cause pain at the time of menstruation and a sensation of fulness and 
distention in the pelvic organs. Neuralgia of the sacral nerves may be 
caused by an overloaded sigmoid flexure. The faeces collect chiefly in the 
colon. Even in extreme grades of constipation it is rare to find dry faeces 
in the caecum. The faeces may form large tumors at the hepatic or splenic 
flexures, or a sausage-like, doughy mass above the navel, or an irregular 
lumpy tumor in the left inguinal region. In old persons the sacculi of the 
colon become distended and the scybala may remain in them and undergo 
calcification, forming enteroliths. 

Tn cases with prolonged retention the faecal masses become channelled 
and diarrhoea may occur for days before the true condition is discovered 
by rectal or external examination. In women who have been habitually 



540 



DISEASES OF THE DIGESTIVE SYSTEM. 



constipated, attacks of diarrhoea with nausea and vomiting should excite 
suspicion and lead to a thorough examination of the large bowel. Fever 
may occur in these cases, and Meigs has reported an instance in which 
the condition simulated typhoid fever. 

Constipation in infants is a common and troublesome disorder. The 
causes are congenital, dietetic, and local. There are instances in which 
the child is constipated from birth and may not have a natural movement 
for years and yet thrive and develop. An instance of the kind was in my 
ward recently in which a baby of seven months had never had a movement 
without preliminary injections. The abdomen became swollen every day, 
but subsided after an injection and the passage of a long catheter. No 
stricture could be felt. There are cases of enormous dilatation of the large 
bowel with persistent constipation. The condition appears sometimes to 
be a congenital defect. In some of these patients there may be constricting 
bands, or, as in a case of Cheever's, a congenital stricture. 

Dietetic causes are more common. In sucklings it often arises from 
an unnatural dryness of the small residue which passes into the colon, and 
it may be very difficult to decide whether the fault is in the mother's milk 
or in the digestion of the child. Most probably it is in the latter, as some 
babies may be persistently costive on natural or artificial foods. Defi- 
ciency of fat in the milk is believed by some writers to be the cause. In 
older children it is of the greatest importance that regular habits should 
be enjoined. Carelessness on the part of the mother in this matter often 
lays the foundation of troublesome constipation in after life. Impairment 
of the contractility of the intestinal wall in consequence of inflammation, 
disturbance in the normal intestinal secretions, and mechanical obstruc- 
tion by tumors, twists, and intussusception are the chief local causes. 

Treatment.' — Much may be done by systematic habits, particularly 
in the young. The desire to go to stool should always be granted. Exer- 
cise in moderation is helpful. In stout persons and in women with pend- 
ulous abdomens the muscles should have the support of a bandage. Fric- 
tion or regularly applied massage is invaluable in the more chronic cases. 
A good substitute is a metal ball weighing from four to six pounds, which 
may be rolled over the abdomen every morning for five or ten minutes. 
The diet should be light, with plenty of fruit and vegetables, particularly 
salads and tomatoes. Oatmeal is usually laxative, though not to all; brown 
bread is better than that made from fine white flour. Of liquids, water 
and aerated mineral waters may be taken freely. A tumblerful of cold 
water on rising, taken slowly, is efficacious in many cases. A glass of hot 
water at night may also be tried alone. A pipe or a cigar after breakfast 
is with many men an infallible remedy. 

When the condition is not very obstinate it is well to try to relieve it 
by hygienic and dietetic measures. If drugs must be used they should be 
the milder saline laxatives or the compound liquorice powder. Enemata 
are often necessary, and it is much preferable to employ them early than 
to constantly use purgative pills. Glycerin either in the form of sup- 
pository or as a small injection is very valuable. Half a drachm of boric 
acid placed within the rectum is sometimes efficacious. The injections of 



ENTEROPTOSIS. 



541 



tepid water, with or without soap, may be used for a prolonged period with 
good effect and without damage. The patient should be in the dorsal 
position with the hips elevated, and it is best to let the fluid flow in slowly 
from a fountain syringe. 

The usual remedies employed are often useless in the constipation asso- 
ciated' with contracted bowel. A very satisfactory measure is the olive-oil 
injection as recommended by Kussmaul. The patient lies on the back with 
the hips elevated, and with a cannula and tube from 15 to 20 ounces 
of pure oil are allowed to flow slowly (or are injected) into the bowel. The 
operation should take at least fifteen minutes. This may be repeated every 
day until the intestine is cleared, and subsequently a smaller injection every 
few days will suffice. 

There are various drugs which are of special service, particularly the 
combination of ipecacuanha, nux vomica, or belladonna, with aloes, rhu- 
barb, colocynth, or podophyllum Meigs recommends particularly the com- 
bination of extract of belladonna (gr. y^), extract of nux vomica (gr. ^), 
and extract of colocynth (gr. ij), one pill to be taken three times a day. 
In anaemia and chlorosis, a sulphur confection taken in the morning, 
and a pill of iron, rhubarb, and aloes throughout the day, are very service- 
able. 

In children the indications should be met, as far as possible, by hygienic 
and dietetic measures. In the constipation of sucklings a change in the 
diet of the mother may be tried, or from one to three teaspoonfuls of cream 
may be given before each nursing. In artificially fed children the top 
milk with the cream should be used. Drinking of water, barley water, or 
oatmeal water will sometimes obviate the difficulty. If laxatives are re- 
quired, simple syrup, manna, or olive oil may be sufficient. The conical 
piece of soap, so often seen in nurseries, is sometimes efficacious. Massage 
along the colon may be tried. Small injections of cold water may be used. 
Large injections should be avoided, if possible. If it is necessary to give 
a laxative by the mouth, castor oil or the fluid magnesia is the best. If 
there are signs of gastro-intestinal irritation, rhubarb and soda or gray 
powder may be given. In older children the diet should be carefully 
regulated. 

V. ENTEROPTOSIS (GUnard's Disease). 

Definition. — " Dropping of the viscera," visceroptosis, is not a disease, 
but a symptom group characterized by looseness of the mesenteric and peri- 
toneal attachments, so that the stomach, the intestines, particularly the 
transverse colon, the liver, the kidneys, and the spleen occupy an abnor- 
mally low position in the abdominal cavity. 

Symptoms and Physical Signs.— It is important to recognize two 
groups of cases. In one the splanchnoptosis follows the loss of normal sup- 
port of the abdominal wall in consequence of repeated pregnancies or re- 
curring ascites. The condition may be extreme without the slightest dis- 
tress on the part of the patient. 

The second and more important group occurs usually in young persons, 



542 DISEASES OF THE DIGESTIVE SYSTEM. 



who present, with splanchnoptosis, the features of more or less marked neu- 
rasthenia. 

In the first group inspection of the abdomen shows a very relaxed ab- 
dominal wall, and as a rule the lineae albicantes of recurring pregnancies. 
Peristalsis of the intestines may be seen, and in extreme cases the outlines of 
the stomach itself with its waves of peristalsis. On inflating the stomach 
with carbonic-acid gas the organ stands out with great prominence, and 
the lesser and greater curvatures are seen, the latter extending perhaps a 
hand's breadth below the level of the navel. The waves of peristalsis are 
feeble and without the vigor and force of those seen in the stomach dilated 
from stricture of the pylorus. The condition of descensus ventriculi with 
atony is best studied in this group of cases. An important point to remem- 
ber is that it may exist in an extreme grade without symptoms. 

In the other group is embraced a somewhat motley series of cases, in 
which, with a pronounced nervous, or, as we call it now, neurasthenic basis, 
there are displacements of the viscera with symptoms. The patients are 
usually young, more frequently women than men, and of spare habit. The 
condition may follow an acute illness with wasting. They complain, as a 
rule, of dyspepsia, throbbing in the abdomen, and dragging pains or weak- 
ness in the back, and inability to perform the usual duties of life. A very 
considerable proportion of all the cases of neurasthenia present the local 
features of enteroptosis. When preparing for the examination one notices 
usually an erythematous flushing of the skin; the scratch of the nail is fol- 
lowed instantly by a line of hyperemia, less often of marked pallor. The 
pulsation of the abdominal aorta is readily seen. 

On examination of the viscera one finds the following: The stomach is 
below the normal level, and in women who have laced it may be vertically 
placed. The splashing or clapotage is unusually distinct. After inflation 
with carbonic-acid gas the outlines of the stomach are seen through the 
thin abdominal walls. In extreme cases there may be great dilatation of 
the stomach, in consequence of obstruction of the pylorus by pressure of the 
displaced right kidney. 

Nephroptosis, or displacement of the kidney, is one of the most constant 
phenomena in enteroptosis. It is well, perhaps, to distinguish between 
the kidney which one can just touch on deep inspiration — palpable kidney, 
one which is freely movable, and which on deep inspiration descends so that 
one can put the ringers of the palpating hand above it and hold it down, 
and, thirdly, a floating kidney, which is entirely outside the costal arch, 
is easily grasped in the hand, readily moved to the middle line, and low 
down toward the right iliac fossa. It is held by some that the designa- 
tion floating kidney should be restricted to the cases in which there is a 
meso-nephron, but this is excessively rare, while extreme grades of renal 
mobility are common. Some of the more serious sequences of movable 
kidney, namely, Dietl's crises and intermittent hydronephrosis, will be con- 
sidered with diseases of the kidney. 

Displacement of the liver is very much less common. In thin women 
who have laced the organ is often tilted forward, so that a very large sur- 
face of the lobes comes in contact with the abdominal wall; it is a very 



ENTEROPTOSIS. 



543 



-common mistake under these circumstances to think that the organ is en- 
larged. Dislocation of the liver itself will be considered later. 

Mobility of the spleen is sometimes very marked in enteroptosis. In 
an extreme grade it may be found in almost any region of the abdomen. It 
is very frequently mistaken for a fibroid or ovarian tumor. A considerable 
proportion of the cases come first under the care of the gynecologist. 

There is usually much relaxation of the mesentery and of the peritoneal 
folds which support the intestines. The colon is displaced downward (co- 
loptosis), with consequent kinking at the flexures. The descent may be so 
low that the transverse colon is at the brim of the pelvis. It may indeed 
be fixed or bent in the form of a V. It is frequently to be felt, as Glenard 
states, as a firm cord crossing the abdomen at or below the level of the 
navel. This kinking may take place not only in the colon, but at the 
pylorus, where the duodenum passes into the jejunum, and where the ileum 
enters the caecum. 

The explanation of the phenomena accompanying enteroptosis is by no 
means easy. It has been suggested by Glenard and others that the vascular 
disturbances in the abdominal viscera in consequence of displacements 
and kinking account for the feelings of exhaustion and general nervous- 
ness. In a large proportion of the cases, however, no symptoms develop 
until after an illness or some protracted nervous strain. 

Treatment. — In a majority of all cases four indications are present: 
To treat the existing neurasthenia, to relieve the nervous dyspepsia, to 
overcome the constipation, and to afford mechanical support to the organs. 
Three of these are considered under their appropriate sections. In cases in 
which the enteroptosis has followed loss in weight after an acute illness or 
worries and cares, an important indication is to fatten the patient. 

A well adapted abdominal bandage is one of the most important meas- 
ures in enteroptosis. In many of the milder grades it alone suffices. I 
know of no single simple measure which affords relief to distressing symp- 
toms in so many cases as the abdominal bandage. It is best made of linen, 
should fit snugly, and should be arranged with straps so that it cannot ride 
up over the hips. A special form must be used, as will be mentioned later, 
for movable kidney. Some of the more aggravated types of enteroptosis are 
combined with such features of neurasthenia that a rigid Weir Mitchell 
treatment is indicated. In a few very refractory cases surgical interference 
may be called for. Treves, in Allbutt's System, records two cases, one in 
which the laparotomy was resorted to as a medical measure with perfect 
results. In the other the liver was stitched in place, and complete recovery 
followed. 

And Lastly, the physician must be careful in dealing with the subjects 
of enteroptosis not to lay too much stress on the disorder. It is well never 
to tell the patient that a kidney is movable; the symptoms may date from 
a knowledge of the existence of the condition. 



34 



544 



DISEASES OF THE DIGESTIVE SYSTEM. 



VI. MISCELLANEOUS AFFECTIONS. 

I. MUCOUS COLITIS. 

This affection is known by various names, such as membranous enteritis?., 
tubular diarrhoea, and mucous colic. It is a remarkable disease, to which, 
much attention has been paid for several centuries. An exhaustive de- 
scription of it is given by Woodward, in vol. ii of the Medical and Surgical . 
Eeports of the Civil War. It is an affection of the large bowel, character- 
ized by the production of a very tenacious adherent mucus, which may be 
passed in long strings or as a continuous, tubular membrane. I have twice - 
had opportunities of seeing this membrane in situ, closely adherent to the 
mucosa of the colon, but capable of separation without any lesion of the 
surface. Judging from the statement of English authors as to its rarity, 
it would appear to be a more frequent disease in this country, in which it 
has been carefully studied by Da Costa, Edwards, and others. According 
to Edwards, 80 per cent of the recorded adult cases have been in women. 
It occurs occasionally in children. Of 111 cases 6 were under the age of 
ten. The cases are almost invariably seen in nervous or hysterical women 
or in men with neurasthenia. All grades of the affection occur, from the 
passage of a slimy mucus, like frog-spawn, to large tubular casts a foot or 
more in length. Microscopically the casts are, as shown by Sir Andrew 
Clark, not fibrinous, but mucoid, and even the firmest consist of dense,, 
opaque, transformed mucus. The disease is a secretion neurosis of the 
colon. There are two groups of cases: (1) neurotic and hysterical, in 
men and women; (2) cases due to local, uterine, tubal, and ovarian trouble. 

Symptoms. — The disease persists for years, varying extremely irom 
time to time, and is characterized by paroxysms of pain in the abdomen, 
tenderness, occasionally tenesmus, and the passage of flakes or long strings 
of mucus, sometimes of definite casts of the bowel. There is frequently 
a spot of great tenderness just between the navel and the left costal border. 
The attacks last for a day or, in some instances, for ten days or two weeks. 
Mental emotions and worry of any sort seem particularly apt to bring on 
an attack. Occasionally errors in diet or dyspepsia precede an outbreak. 
Membranes are not passed with every paroxysm, even when the pains and 
cramps are severe. There are instances in which the morphia habit has-, 
been contracted on account of the severity of the pain. There may be 
marked nervous symptoms, and authors mention hysterical outbreaks, hypo- 
chondriasis, and melancholia. Blood may be passed in rare instances. The 
condition may persist for years and lead to great emaciation and chronic 
invalidism. Constipation is a special feature in many cases. Herringham 
states that he knew of three cases of mucous colitis in which death had sud- 
denly occurred, in all with great pain in the left side of the abdomen. In 
another case there was an abscess in the region of the descending colon. 

The diagnosis is rarely doubtful, but it is important not to mistake the 
membranes for other substances; thus, the external cuticle of asparagus 
and undigested portions of meat or sausage-skins sometimes assume forms 
not unlike mucous casts, but the microscopical examination will quickly 



MISCELLANEOUS AFFECTIONS. 



545 



differentiate them. Twice I have known mucous colitis with severe pain 
to be mistaken for appendicitis. 

The treatment is very unsatisfactory. Drugs are of doubtful benefit. 
Measures directed to the nervous condition are perhaps most important. 
Sometimes local treatment with Kelly's long rectal tubes is beneficial. 
Systematic high irrigation of the colon should be practiced. Eight inguinal 
colotomy has been performed with success in several cases of great ob- 
stinacy. The artificial anus should remain open for some time. 

II. DILATATION OF THE COLON. 

Hale White, in Allbutt's System, recognizes four groups of cases. 
In the first the distention is entirely gaseous, and occurs not infrequently 
as a transient condition. In many cases it has an important influence, inas- 
much as it may be extreme, pushing up the diaphragm and seriously im- 
pairing the action of the heart and lungs. H. Fenwick has called attention 
to this as occasionally a cause of sudden heart-failure. 

In the second group are the cases in which the distention of the colon 
is caused by solid substances, as fascal matter, occasionally by foreign bodies 
introduced from without, and more rarely by gall-stones. 

In a third group are embraced the cases in which the dilatation is due 
to an organic obstruction in front of the dilated gut. Under these circum- 
stances the colon may reach a very large size. These cases are common 
enough in malignant tumors and sometimes in volvulus. Dilatation of the 
sigmoid flexure occurs particularly when this portion of the bowel is con- 
genially very long. In such cases the bowel may be so distended that it 
occupies the greater part of the abdomen, pushing up the liver and the 
diaphragm. An acute condition is sometimes caused by a twist in the 
meso-colon. 

Fourthly, there are the cases of so-called idiopathic dilatation of the 
colon. The condition has been very carefully studied by Kolleston, C. F. 
Martin, and others. I have had four well-marked instances under my care. 
Treves suggests that the condition is always due to a narrowing low down in 
the colon. This proved to be true in Case II of my series, a boy who died 
at the age of about two and a half years. There was a distinct stricture in 
the sigmoid flexure. In the idiopathic chronic form the gut reaches an 
enormous size. The coats may be hypertrophiecl without evidence of any 
special organic change in the mucosa. The most remarkable instance has 
been reported by Formad. The patient, known as the "balloon-man," aged 
twenty-three years at the time of his death, had had a distended abdomen 
from infancy. Post mortem the colon was found as large as that of an ox, 
the circumference ranging from 15 to 30 inches. The weight with the con- 
tents was 17 pounds. The condition is incurable, and surgical interference 
should be probably the only measure. In one of my cases good results fol- 
lowed the establishment of ail artificial anus, but the most brilliant case 
is that reported recently by Treves, who excised the greater part of the 
colon, with recovery. 



546 



DISEASES OF THE DIGESTIVE SYSTEM. 



III. INTESTINAL SAND. 

" Sable Intestinal." — Biliary gravel may be passed in large amount, and 
the seeds of raspberries, etc., may occur in the faeces in extraordinary num- 
bers. Delepine, Shattock, and others have described in the faeces saburrous 
matter consisting of spheroidal aggregations of vegetable sclerenchymatous 
cells, such as occur in pears. In Shattock' s patient the discharge was in- 
termittent, but it could always be brought away by an aperient. I have re- 
cently seen a case in which the patient on two occasions passed a consider- 
able quantity of sand. The sample which he brought consisted of small 
grains, some of a beautiful garnet color. They proved to be vegetable 
matter. 

IV. AFFECTIONS OF THE MESENTERY. 

There are various diseases of the structures embraced in the mesentery, 
which are of more or less importance. 

(1) Haemorrhage (luematoma). — Instances in which the bleeding is con- 
fined to the mesenteric tissues are rare; more commonly the condition is 
associated with haemorrhagic infiltration of the pancreas and with retro- 
peritoneal haemorrhage. It occurs in ruptures of aneurisms, either of the 
abdominal aorta or of the superior mesenteric artery, in malignant forms 
of the infectious fevers, as small-pox, and, lastly, in individuals in whom 
no predisposing conditions exist. In 1887, at the Philadelphia Hospital, 
there was a patient in the ward of my colleague, Bruen, who had obscure 
abdominal symptoms for several days with great pain and prostration. I 
found at the post mortem the greater portion of the mesentery and the 
retro-peritoneal tissues infiltrated with large blood-clots. There was no 
disease of the aorta or of the branches of the cceliac axis or of the mesen- 
teric vessels. Isambard Owen has reported a case of sudden death in a 
woman aged sixty-seven from haemorrhage in the transverse meso-colon. 

(2) Affections of the Mesenteric Arteries. — (a) Aneurism (see under 
Arteries). 

(b) Embolism and Thrombosis — Infarction of the Bowel. — When the 
mesenteric vessels are blocked by emboli or thrombi the condition of in- 
farction follows in the territory supplied. Probably the occlusion of small 
vessels does not produce any symptoms, and the circulation may be re- 
established. If the superior mesenteric artery is blocked, a serious and fatal 
condition follows. Three instances have come under my observation. In 
one, a woman aged fifty-five was seized with nausea and vomiting, which 
persisted for more than a week. There was pain in the abdomen, tym- 
panites, and toward the close the vomiting was incessant and faecal. The 
autopsy showed great congestion, with swelling and infiltration of the jeju- 
num and ileum. The superior mesenteric artery was blocked at its orifice 
by a firm thrombus. In the second case, a woman aged seventy-five was 
seized with severe abdominal pain and frequent vomiting. At first there 
was diarrhoea; subsequently the symptoms pointed to obstruction, with 
great distention of the abdomen. The post mortem showed the small 
bowel, with the exception of the first foot of the jejunum and the last six 



MISCELLANEOUS AFFECTIONS. 



547 



inches of the ileum, greatly distended and deeply infiltrated with blood. 
The mesentery was also congested and infiltrated. The superior mesen- 
teric artery contained a firm brownish-yellow clot. There were many re- 
cent warty vegetations on the mitral valve. In the third case, a man aged 
forty was suddenly seized with intense pain in the abdomen, became faint, 
fell to the ground, and vomited. For a week he had persistent vomiting, 
severe diarrhoea, tympanites, and great pain in the abdomen. The stools 
were thin and at times blood-tinged. The autopsy showed an aneurism 
involving the aorta at the diaphragm. The superior mesenteric artery, half 
an inch from its origin on the sac, was blocked by a portion of the fibrinous 
clot of the aneurism. Watson has analyzed the symptoms in 27 cases; in 
18 there was pain, usually colicky and violent; diarrhoea occurred in 14; 
vomiting in 14; and abdominal distention in 12. In a majority of the 
cases the heart or the abdominal aorta was diseased. In one sixth of the 
cases the lesion was limited enough to have permitted the successful re- 
section of the bowel. J. W. Elliot has operated upon two cases of in- 
farction of the bowel, in one of which (thrombosis of the mesenteric 
veins) he successfully resected forty-eight inches. In the horse, infarction 
of the intestine is extremely common in connection with the verminous 
aneurisms of the mesenteric arteries, and is the usual cause of colic in this 
animal. 

(3) Diseases of the Mesenteric Veins. — Dilatation and sclerosis occur in 
cirrhosis of the liver. In instances of prolonged obstruction there may 
be large saccular dilatations with calcification of the intima, as in a case of 
obliteration of the vena portae described by me. Suppuration of the mes- 
enteric veins is not rare, and occurs usually in connection with pylephlebitis. 
The mesentery may be much swollen and is like a bag of pus, and it is only 
on careful dissection that one sees that the pus is really within channels 
representing extremely dilated mesenteric veins. Two of the three cases 
I have seen were in connection with local appendix abscess. 

(4) Disorders of the Chyle Vessels.— Varicose, cavernous, and cystic 
clivlangiomata are met with in the mucosa and submucosa of the small in- 
testine, occasionally of the stomach. Extravasation of chyle into the mes- 
enteric tissue is sometimes seen. Chylous cysts are found. I saw one the 
size of an egg at the root of the mesentery. Bramann records a case in 
a man aged sixty-three, in which a cyst of this kind the size of a child's 
head was healed by operation. There is an instance on record of a con- 
genital malformation of the thoracic duct, in which the receptaculum 
formed a flattened cyst which discharged into the peritonaeum, and a chylous 
ascitic fluid was withdrawn on several occasions. Homans, of Boston, re- 
ports an extraordinary case of a girl, who from the third to the thirteenth 
year had an enlarged abdomen. Laparotomy showed a series of cysts con- 
taining clear fluid. They were supposed to be dilated lymph vessels con- 
nected with the intestines. 

(5) Cysts of the Mesentery.— Much attention has been directed of late 
years to the occurrence of mesenteric cysts, and the literature which is 
fully given by Delmez (Paris Thesis, 1891) is already extensive. They 
may be either dermoid, hydatid, serous, sanguineous, or chylous. They 



548 



DISEASES OF THE DIGESTIVE SYSTEM. 



occur at any portion of the mesentery, and range from a few inches in 
diameter to large masses occupying the entire abdomen. They are fre- 
quently adherent to the neighboring organs, to the liver, spleen, uterus, and 
sigmoid flexure. 

The symptoms usually are those of a progressively enlarging tumor in 
the abdomen. Sometimes a mass develops rapidly, particularly in the 
hemorrhagic forms. Colic and constipation are present in some cases. 
The general health, as a rule, is well maintained in spite of the progres- 
sive enlargement of the abdomen, which is most prominent in the um- 
bilical region. Mesenteric cysts may persist for many years, even ten or 
twenty. 

The diagnosis is extremely uncertain, and no single feature is in any 
way distinctive. Augagneur gives three important signs: the great mo- 
bility, the situation in the middle line, and the zone of tympany in front 
of the tumor. Of these, the second is the only one which is at all con- 
stant, as when the tumors are large the mobility disappears, and at this 
stage the intestines, too, are pushed to one side. It is most frequently mis- 
taken for ovarian tumor. Movable kidney, hydronephrosis, and cysts of 
the omentum have also been confused with it. In certain instances punc- 
ture may be made for diagnostic purposes, but it is better to advise lapa- 
rotomy for the purpose of drainage, or, if possible, enucleation may be prac- 
tised. * 

YIII. DISEASES OF THE LIYEE. 

I. JAUNDICE {Icterus). 

Definition. — Jaundice or icterus is a condition characterized by col- 
oration of the skin, mucous membranes, and fluids of the body by the bile- 
pigment. 

For a full consideration of the theories of jaundice the reader is referred 
to William Hunter's article in AllbutFs System of Medicine. The cases 
with icterus may be divided into two great groups. 

1. Obstructive Jaundice. 

The following classification of the causes of obstructive jaundice is given 
by Murchison: (1) Obstruction by foreign bodies within the ducts, as gall- 
stones and parasites; (2) by inflammatory tumefaction of the duodenum or 
of the lining membrane of the duct; (3) by stricture or obliteration of the 
duct; (4) by tumors closing the orifice of the duct or growing in its inte- 
rior; (5) by pressure on the duct from without, as by tumors of the liver 
itself, of the stomach, pancreas, kidney, or omentum; by pressure of en- 
larged glands in the fissures of the liver, and, more rarely, of abdominal 
aneurism, faecal accumulation, or the pregnant uterus. 

To these causes some add lowering of the blood pressure in the portal 
system so that the tension in the smaller bile-ducts is greater than in the 
blood-vessels. For this view, however, there is no positive evidence. In 



JAUNDICE. 



549 



this class may perhaps be placed the cases of jaundice from mental shock 
•or depressed emotions, which " may conceivably cause spasm and reversed 
peristalsis of the bile-duct " (W. Hunter). 

General Symptoms of Obstructive Jaundice. — (1) Icterus, or tinting of 
■the skin and conjunctivae. The color ranges from a lemon-yellow in catar- 
rhal jaundice to a deep olive-green or bronzed hue in permanent obstruc- 
tion. In some instances the color of the skin is greenish black, the so- 
called " black jaundice." 

(2) Of the other cutaneous symptoms, pruritus in the more chronic forms, 
may be intense and cause the greatest distress. It may precede the onset 
of the jaundice, but as a rule it is not very marked except in cases of pro- 
longed obstruction. Sweating is common, and may be curiously localized 
to the abdomen or to the palms of the hands. Lichen, urticaria, and boils 
may develop, and the skin disease known as xanthelasma or vitiligoidea. 
The jaundice may be due to the extension of the xanthomata to the .bile- 
passages. The visceral localization of this disorder has been chiefly ob- 
served when there are numerous punctate tubercles on the limbs (Hallo- 
peau). In very chronic cases telangiectases develop in the skin, sometimes 
in large numbers over the body and face, occasionally on the mucous mem- 
brane of the tongue and lips, forming patches of a bright red color from 
1 to 2 cm. in breadth. 

(3) The secretions are colored with bile-pigment. The sweat tinges 
the linen; the tears and saliva and milk are rarely stained. The expectora- 
tion is not often tinted unless there is inflammation, as when pneumonia 
coexists with jaundice. The urine may contain the pigment before it is 
apparent in the skin or conjunctiva. The color varies from light greenish 
yellow to a deep black-green. Gmelin's test is made by allowing five or 
six drops of urine and a similar amount of common nitric acid to flow 
together slowly on the flat surface of a white plate. A play of colors is 
produced — various shades of green, yellow, violet, and red. In cases of 
jaundice of long standing or great intensity the urine usually contains 
albumin and always bile-stained tube-casts. 

(4) No bile passes into the intestine. The stools therefore are of a 
pale drab or slate-gray color, and usually very fetid and pasty. There 
may be constipation; in many instances, owing to decomposition, there is 
diarrhoea. 

(5) Slow pulse. The heart's action may fall to 40, 30, or even to 20 
per i ii i mite. It is particularly noticeable in the cases of catarrhal jaundice, 
and is not as a rule an unfavorable symptom. The respirations may fall 
to 10 or even to 7 per minute. 

((')) I hemorrhage. The tendency to bleeding in chronic icterus is a se- 
rious feature in some cases. It has been shown that the blood coagulation 
time may be much retarded, and instead of from three minutes and a half 
to foui- minutes and a half we have found it in some cases as late as eleven 
or twelve id i miles. This is a point which should be taken account of by 
Burgeons, inasmuch as incontrollable haemorrhage is a well-recognized acci- 
dent in operating upon patients with chronic obstructive jaundice. Pur- 
pura, large subcutaneous extravasations, more rarely haemorrhages from the 



550 



DISEASES OF THE DIGESTIVE SYSTEM. 



mucous membranes, occur in protracted jaundice, and in the more severe 
forms. 

(7) Cerebral symptoms. Irritability, great depression of spirits, or even 
melancholia may be present. In any case of persistent jaundice special 
nervous phenomena may develop and rapidly prove fatal — such as sudden 
coma, acute delirium, or convulsions. Usually the patient has a rapid 
pulse, slight fever, and a dry tongue, and he passes into the so-called " ty- 
phoid state. " These features are not nearly so common in obstructive as 
in febrile jaundice, but they not infrequently terminate a chronic icterus 
in whatever way produced. The group of symptoms has been termed 
cliolcemia or, on the supposition that cholesterin is the poison, cliolester- 
cemia; but its true nature has not yet been determined. In some of the 
cases the symptoms may be due to uraemia. 

2. Toxemic JArxDiCE. 

In this form there is no obstruction in the bile-passages, but the jaundice 
is associated with toxic states of the blood, dependent upon various poisons 
which either act directly on the blood itself or in some cases on the liver- 
cells as well. The term haematogenous jaundice was formerly applied to 
this group in contradistinction to the hepatogenous jaundice, associated 
with obstructive changes in the bile-passages. Hunter groups the causes 
as follows: 

1. Jaundice produced by the action of poisons, such as toluylendiamin, 
phosphorus, arsenic, snake-venom. 

2. Jaundice met with in various specific fevers and conditions, such as- 
yellow fever, malaria (remittent and intermittent), pyaemia, relapsing fever,, 
typhus, enteric fever, scarlatina. 

3. Jaundice met with in various conditions of unknown but more or 
less obscure infective nature, and variously designated as epidemic, infec- 
tious, febrile, malignant jaundice, icterus gravis, WeiFs disease, acute yel- 
low atrophy. 

The symptoms of toxic jaundice are not nearly so striking as in the ob- 
structive variety. The bile is usually present in the stools, sometimes in 
excess, causing very dark movements. The skin has in many cases only a 
light lemon tint. In the severer forms, as in acute yellow atrophy, the 
color may be more intense, but in malaria and pernicious anaemia the tint 
is usually light. In these mild cases the urine may contain little or no bile- 
pigment, but the urinary pigments are considerably increased. In many 
cases of the toxic variety the constitutional disturbance is very profound, 
and there are high fever, delirium, convulsions, suppression of urine, black 
vomit, and cutaneous haemorrhages. 

In connection with the various fevers, malaria, yellow fever, and Weil's 
disease jaundice has been described. Two special affections may here re- 
ceive consideration, the icterus of the new-born and acute yellow atrophy. 



ACUTE YELLOW ATROPHY. 



551 



II. ICTERUS NEONATORUM. 

Xew-born infants are liable to jaundice, which in some instances rapidly 
proves fatal. A mild and a severe form may be recognized. 

The mild or physiological icterus of the new-born is a common disease 
in foundling hospitals, and is not very infrequent in private practice. In 
900 consecutive births at the Sloane Maternity, icterus was noted in 300 
cases (Holt). The discoloration appears early, usually on the first or sec- 
ond day, and is of moderate intensity. The urine may be bile-stained and 
the faeces colorless. The nutrition of the child is not usually disturbed, 
and in the majority of cases the jaundice disappears within two weeks. 
This form is never fatal. The cause of this jaundice is not at all clear. 
Some have attributed it to stasis in the smaller bile-ducts, which are com- 
pressed by the distended radicals of the portal vein. Others hold that the 
jaundice is due to the destruction of a large number of red blood-corpuscles 
during the first few days after birth. 

The severe form of icterus in the new-born may depend upon (a) con- 
genital absence of the common or hepatic duct, of which there are several 
instances on record; (b) congenital syphilitic hepatitis; and (c) septic poi- 
soning, associated with phlebitis of the umbilical vein. This is a severe 
and fatal form, in which also haemorrhage from the cord may occur. 

III. ACUTE YELLOW ATROPHY {Malignant Jaundice; Icterus Gravis). 

Definition. — Jaundice associated with marked cerebral symptoms and 
characterized anatomically by extensive necrosis of the liver-cells with re- 
duction in volume of the organ. 

Etiology. — This is a rare disease. No case has been admitted to the 
Johns Hopkins Hospital in the eleven years of its work. Hunter has col- 
lected only 50 cases between 1880 and 1894 (inclusive), which brings up 
the total number of recorded cases to about 250. In a somewhat varied 
post-mortem and clinical experience no instance has fallen under my ob- 
servation. On the other hand, a physician may see several cases within a 
few years, or even within a few months, as happened to Eeiss, who saw five 
cases within three months at the Charite, in Berlin. The disease seems 
to be rare in this country. It is more common in women than in men. Of 
the 100 cases collected by Legg, 69 were in females; and of Thierfelder's 
143 cases, 88 were in women. There is a remarkable association between 
the disease and pregnancy, which was present in 25 of the 69 women in 
Legg's statistics, and in 33 of the 88 women in Thierfelder's collection. 
It i- mosl common between the ages of twenty and thirty, but lias been met 
with as early as the fourth day and the tenth month. It has followed 
fright or profound mental emotion. In hypertrophic cirrhosis the symp- 
toms of a profound icterus gravis may develop, with all the clinical features 
of acute yellow atrophy, including the presence of leucin and tyrosin in the 
urine, and convulsions. I have seen two such cases; in both there were 



£52 DISEASES OF THE DIGESTIVE SYSTEM. 

extensive necroses in the liver-cells. Though the symptoms produced by 
phosphorus poisoning closely simulate those of acute yellow atrophy, the 
two conditions are not identical. 

Morbid Anatomy. — The liver is greatly reduced in size, looks thin 
and flattened, and sometimes does not reach more than one half or even 
one third of its normal weight. It is flabby and the capsule is wrinkled. 
•On section the color may be yellowish brown, yellowish red, or mottled, and 
the outlines of the lobules are indistinct. The yellow and dark-red por- 
tions represent different stages of the same process — the yellow an earlier, 
the red a more advanced stage. The organ may cut with considerable firm- 
ness. Microscopically the liver-cells are seen in all stages of necrosis, and 
in spots appear to have undergone complete destruction, leaving a fatty, 
granular debris with pigment grains and crystals of leucin and tyrosin. 
The bile-ducts and gall-bladder are empty. Hunter concludes that it is a 
toxaemic catarrh of the finer bile-ducts, similar to that which is found after 
poisoning by toluylendiamin or phosphorus. 

The other organs show extensive bile-staining, and there are numerous 
haemorrhages. The kidneys may show marked granular degeneration of 
the epithelium, and usually there is fatty degeneration of the heart. In a 
majority of the cases the spleen is enlarged. 

Symptoms. — In the initial stage there is a gastro-duodenal catarrh, 
.and at first the jaundice is thought to be of a simple nature. In some in- 
stances this lasts only a few days, in others two or three weeks. Then 
severe symptoms set in — headache, delirium, trembling of the muscles, and, 
:in some instances, convulsions. Vomiting is a constant symptom, and blood 
may be brought up. Haemorrhages occur into the skin or from the mucous 
surfaces; in pregnant women abortion may occur. With the development 
of the head symptoms the jaundice usually increases. Coma sets in and 
gradually deepens until death. The body temperature is variable; in a 
majority of the cases the disease runs an afebrile course, though sometimes 
just before death there is an elevation. In some instances, however, there 
has been marked pyrexia. The pulse is usually rapid, the tongue coated 
and dry, and the patient is in a " typhoid state/' 

The urine is bile-stained and often contains tube-casts. Leucin and 
tyrosin are not constantly present; of 23 recent cases collected by Hunter, 
in 9 neither was found; in 10 both were present; in 3 tyrosin only; in 1 
leucin only. The leucin occurs as rounded disks, the tyrosin in needle- 
shaped crystals, arranged either in bundles or in groups. The tyrosin may 
sometimes be seen in the urine sediment, but it is best first to evaporate a 
few drops of urine on a cover-glass. In the majority of cases no bile enters 
the intestines, and the stools are clay-colored. The disease is almost in- 
variably fatal. In a few instances recovery has been noted. I saw in 
'Leube's clinic, at Wurzburg, a case which was convalescent. 

Diagnosis. — Jaundice with vomiting; diminution of the liver volume, 
delirium, and the presence of leucin and tryosin in the urine, form a char- 
acteristic and unmistakable group of symptoms. Leucin and tyrosin are 
not; however, distinctive. They may be present in cases of afebrile jaun- 
dice with slight enlargement of the liver. 



AFFECTIONS OF THE BLOOD-VESSELS OF THE LIVER. 553 

It is not to be forgotten that any severe jaundice may be associated with 
intense cerebral symptoms. The clinical features in certain cases of hyper- 
trophic cirrhosis are almost identical, but the enlargement of the liver, the 
more constant occurrence of fever, and the absence of leucin and tyrosin 
are distinguishing signs. Phosphorus poisoning may closely simulate acute 
yellow atrophy, particularly in the haemorrhages, jaundice, and the diminu- 
tion in the liver volume, but the gastric symptoms are usually more marked, 
-and leucin and tyrosin are stated not to occur in the urine. 

No known remedies have any influence on the course of the disease. 



IV. AFFECTIONS OF THE BLOOD-VESSELS OF THE 

LIVER. 

(1) Anaemia. — On the post-mortem table, when the liver looks anaemic, 
as in the fatty or amyloid organ, the blood-vessels, which during life were 
probably well filled, can be readily injected. There are no symptoms in- 
dicative of this condition. 

(2) Hyperemia. — This occurs in two forms, (a) Active hypercemia. 
After each meal the rapid absorption by the portal vessels induces transient 
congestion of the organ, which, however, is entirely physiological; but it 
is quite possible that in persons who persistently eat and drink too much 
this active hyperemia may lead to functional disturbance or, in the case 
of drinking too freely of alcohol, to organic change. In the acute fevers 
-an acute hyperemia may be present. 

The symptoms of active hyperemia are indefinite. Possibly the sense 
of distress or fulness in the right hypochondrium, so often mentioned by 
dyspeptics and by those who eat and drink freely, may be due to this cause. 
There are probably diurnal variations in the volume of the liver. In cir- 
rhosis with enlargement the rapid reduction in volume after a copious 
haemorrhage indicates the important part which hyperaemia plays even in 
organic troubles. It is stated that suppression of the menses or suppression 
of a haemorrhoidal flow is followed by hyperaemia of the liver. Andrew H. 
Smith has described a case of periodical enlargement of the liver. 

(b) Passive Congestion. — This is much more common and results from 
an increase of pressure in the efferent vessels or sub-lobular branches of the 
hepatic veins. Every condition leading to venous stasis in the right heart 
at once affects these veins. 

In chronic valvular disease, in emphysema, cirrhosis of the lung, and 
in intrathoracic tumors mechanical congestion occurs and finally leads to 
very definite changes. The liver is enlarged, firm, and of a deep-red color; 

hepatic vessels are greatly engorged, particularly the central vein in 
•each lobule and its adjacent capillaries. On section the organ presents a 
peculiar mottled appearance, owing to the deeply congested hepatic and 
the anaemic portal territories; hence the term nutmeg which has been given 
to this condition. Gradually the distention of the central capillaries reaches 
such a grade that atrophy of the intervening liver-cells is induced. Brown 
pigment is deposited about the centre of the lobules and the connective 



554 



DISEASES OF THE DIGESTIVE SYSTEM. 



tissue is greatly increased. In this cyanotic induration or cardiac liver the 
organ is large in the early stage, but later it may become contracted. Occa- 
sionally in this form the connective tissue is increased about the lobules as 
well, but the process usually extends from the sublobular and central veins. 

The symptoms of this form are not always to be separated from those 
of the associated conditions. Gastro-intestinal catarrh is usually present 
and haematemesis may occur. The portal obstruction in advanced cases 
leads to ascites, which may precede the development of general dropsy. 
There is often slight jaundice, the stools may be clay-colored, and the urine 
contains bile-pigment. 

On examination the organ is found to be increased in size. It may be 
a full hand's breadth below the costal margin and tender on pressure. It 
is in this condition particularly that we meet with pulsation of the liver. 
We must distinguish the communicated throbbing of the heart, which is 
very common, from the heaving, diffuse impulse due to regurgitation into 
the hepatic veins, in which, when one hand is upon the ensiform cartilage 
and the other upon the right side at the margin of the ribs, the whole 
liver can be felt to dilate with each impulse. 

The indications for treatment in passive hyperemia are to restore the 
balance of the circulation and to unload the engorged portal vessels. In 
cases of intense hyperemia 18 or 20 ounces of blood may be directly 
aspirated from the liver, as advised by George Harley and practised by 
many Anglo-Indian physicians. Good results sometimes follow this he- 
pato-phlebotomy. The prompt relief and marked reduction in the volume 
of the organ which follow an attack of haBmatemesis or bleeding from piles 
suggests this practice. Salts administered by Matthew Hay's method de- 
plete the portal system freely and thoroughly. As a rule, the treatment 
must be that of the condition with which it is associated. 

(3) Diseases of the Portal Vein. — (a) Thrombosis; Adhesive Pyle- 
phlebitis. — Coagulation of blood in the portal vein is met with in cirrhosis, 
in syphilis of the liver, invasion of the vein by cancer, proliferative perito- 
nitis involving the gastro-hepatic omentum, perforation of the vein by gall- 
stones, and occasionally follows sclerosis of the walls of the portal vein or 
of its branches (Borrmann). In rare instances a complete collateral circula- 
tion is established, the thrombus undergoes the usual changes, and ulti- 
mately the vein is represented by a fibrous cord, a condition which has been 
called pylephlebitis adhesiva. In a case of this kind which I dissected the 
portal vein was represented by a narrow fibrous cord; the collateral circula- 
tion, which- must have been completely established for years, ultimately 
failed, ascites and haematemesis supervened and rapidly proved fatal.* The 
diagnosis of obstruction of the portal vein can rarely be made. A sug- 
gestive symptom, however, is a sudden onset of the most intense engorge- 
ment of the branches of the portal system, leading to haematemesis, melama, 
ascites, and swelling of the spleen. 

Emboli in the branches of the portal vein do not, as a rule, produce 
infarction, for blood reaches the lobular capillary plexus, as shown by 



* Journal of Anatomy and Physiology, vol. xvii. 



DISEASES OF THE BILE-PASSAGES AND GALL-BLADDER. 555 



Cohnheim and Litten, through the free anastomosis with a hepatic artery. 
In rare instances, however, a condition resembling infarction does occur, 
sometimes in small areas, at others in quite extensive territories. Septic 
emboli, on the other hand, may induce suppuration. 

(b) Suppurative pylephlebitis will be considered in the section on abscess. 

(4) Affections of the hepatic vein are extremely rare. Dilatation oc- 
curs in cases of chronic enlargement of the right heart, from whatever cause 
produced. Emboli occasionally pass from the right auricle into the hepatic 
veins. A rare and unusual event is stenosis of the orifices of the hepatic 
veins, which I met in a case of fibroid obliteration of the inferior vena cava 
and which was associated with a greatly enlarged and indurated liver.* 

(5) Hepatic Artery. — Enlargement of this vessel is seen in cases of cir- 
rhosis of the liver. It may be the seat of extensive sclerosis. Aneurism 
of the hepatic artery is rare, but instances are on record, and will be re- 
ferred to in the section on arteries. 



V. DISEASES OF THE BILE-PASSAGES AND 
GALL-BLADDER. 

(a) Acute Catakeh of the Bile-ducts (Catarrhal Jaundice). 

Definition. — Jaundice due to swelling and obstruction of the terminal 
portion of the common duct. 

Etiology. — General catarrhal inflammation of the bile-ducts is usu- 
ally associated with gall-stones. The catarrhal process now under consid- 
eration is probably always an extension of a gastro-duodenal catarrh, and 
the process is most intense in the pars intestinalis of the duct, which pro- 
jects into the duodenum. The mucous membrane is swollen, and a plug 
of inspissated mucus fills the diverticulum of Vater, and the narrower por- 
tion just at the orifice, completely obstructing the outflow of bile. It is not 
known how widespread this catarrh is in the bile-passages, and whether 
it really passes up the ducts. It would, of course, be possible to have a 
catarrh of the finer ducts within the liver, which some French writers think 
may initiate the attack, but the evidence for this is not strong, and it seems 
more likely that the terminal portion of the duct is always first involved. 
In the only instance which I have had an opportunity to examine post 
mortem the orifice was plugged with inspissated mucus, the common and 
hepatic ducts were slightly distended and contained a bile-tinged, not a 
clear, mucus, and there were no observable changes in the mucosa of the 
ducts. 

This catarrhal or simple jaundice results from the following causes: 
(1) Duodenal catarrh, in whatever way produced, most commonly follow- 
ing ail attack of indigestion. It is most frequently met witli in young 
persons, but may occur at any age, and may follow not only errors in diet, 
but also eold, exposure, and malaria, as well as the conditions associated 
with portal obstruction, chronic heart-disease, and Bright's disease. (2) 



* Journal of Anatomy and Physiology, vol. xvi. 



556 



DISEASES OF THE DIGESTIVE SYSTEM. 



Emotional disturbances may be followed by jaundice, which is believed to> 
be due to catarrhal swelling. Cases of this kind are rare and the anatom- 
ical condition is unknown. (3) Simple or catarrhal jaundice may occur 
in epidemic form. (4) Catarrhal jaundice is occasionally seen in the in- 
fectious fevers, such as pneumonia, and typhoid fever. The nature of acute 
catarrhal jaundice is still unknown. It may possibly be an acute infection. 
In favor of this view are the occurrence in epidemic form and the presence- 
of slight fever. The spleen, however, is not often enlarged. In only 4 
out of 23 cases was it palpable. 

Symptoms. — There may be neither pain nor distress, and the pa- 
tient's friends may first notice the yellow tint, or the patient himself may 
observe it in the looking-glass. In other instances there are dyspeptic 
symptoms and uneasy sensations in the hepatic region or pains in the back 
and limbs. In the epidemic form, the onset may be more severe, with 
headache, chill, and vomiting. Fever is rarely present, though the tem- 
perature may reach 101°, sometimes 102°. All the signs of obstructive 
jaundice already mentioned are present, the stools are clay-colored, and 
the urine contains bile-pigment. The jaundice has a bright-yellow tint; 
the greenish, bronzed color is never seen in the simple form. The pulse 
may be normal, but occasionally it is remarkably slow, and may fall to 40 
or 30 beats in the minute, and the respirations to as low as 8 per minute. 
Sleepiness, too, may be present. The liver may be normal in size, but is 
usually slightly enlarged, and the edge can be felt below the costal margin. 
Occasionally the enlargement is more marked. As a rule the gall-bladder 
cannot be felt. The spleen may be increased in size. The duration of the 
disease is from four to eight weeks. There are mild cases in which the 
jaundice disappears within two weeks; on the other hand, it may persist 
for three months. The stools should be carefully watched, for they give 
the first intimation of removal of the obstruction. 

The diagnosis is rarely difficult. The onset in young, comparatively 
healthy persons, the moderate grade of icterus, the absence of emaciation 
or of evidences of cirrhosis or cancer, usually make the diagnosis easy. 
Cases which persist for two or three months cause uneasiness, as the sus- 
picion is aroused that it may be more than simple catarrh. The absence 
of pain, the negative character of the physical examination, and the main- 
tenance of the general nutrition are the points in favor of simple jaundice. 
There are instances in which time alone can determine the true nature of 
the case. The possibility of Weil's disease must be borne in mind in anom- 
alous types. 

Treatment. — As a rule the patient can keep on his feet from the out- 
set. Measures should be used to allay the gastric catarrh, if it is present. 
A dose of calomel may be given, and the bowels kept open subsequently 
by salines. The patient should not be violently purged. Bismuth and 
bicarbonate of soda may be given, and the patient should drink freely of the 
alkaline mineral waters, of which Vichy is the best. Irrigation of the 
large bowel with cold water may be practised. The cold is supposed to ex- 
cite peristalsis of the gall-bladder and ducts, and thus aid in the expulsion 
of the mucus. 



DISEASES OF THE BILE-PASSAGES AND GALL-BLADDER. 557 



(b) Cheonic Cataeehal Angiocholitis. 

This may possibly occur also as a sequel of the acute catarrh. I have 
never met with an instance, however, in which a chronic, persistent jaundice 
could be attributed to this cause. A chronic catarrh always accompanies 
obstruction in the common duct, whether by gall-stones, malignant disease,, 
stricture, or external pressure. There are two groups of cases: 

(1) With Complete Obstruction of the Common Duct. — In this form the 
bile-passages are greatly dilated, the common duct may reach the size of 
the thumb or larger, there is usually dilatation of the gall-bladder and of 
the ducts within the liver. The contents of the ducts and of the gall- 
bladder are a clear, colorless mucus. The mucosa may be everywhere 
smooth and not swollen. The clear mucus is usually sterile. The patients 
are the subjects of chronic jaundice, usually without fever. 

(2) With Incomplete Obstruction of the Duct. — There is pressure on the 
duct or there are gall-stones, single or multiple, in the common duct or in 
the diverticulum of Vater. The bile-passages are not so much dilated, and 
the contents are a bile-stained, turbid mucus. The gall-bladder is rarely 
much dilated. In a majority of all cases stones are found in it. 

The symptoms of this type of catarrhal angiocholitis are sometimes very 
distinctive. With it is associated most frequently the so-called hepatic in- 
termittent fever, recurring attacks of chills, fever, and sweats. We need: 
still further information about the bacteriology of these cases. In all prob- 
ability the febrile attacks are due distinctly to infection. I cannot too 
strongly emphasize the point that the recurring attacks of intermittent 
fever do not necessarily mean suppurative angiocholitis. The question will, 
be referred to again under gall-stones. 

(c) Suppurative and Ulceeatiye Angiocholitis. 

The condition is a diffuse, purulent angiocholitis involving the larger 
and smaller ducts. In a large proportion of all cases there is associated 
suppurative disease of the gall-bladder. 

Etiology. — It is the most serious of the sequels of gall-stones. Occa- 
sionally a diffuse suppurative angiocholitis follows the acute infectious 
cholecystitis; this, however, is rare, since fortunately in the latter condi- 
tion the cystic duct is usually occluded. Cancer of the duct, foreign bodies, 
such as lumbricoids or fish bones, are occasional causes. And lastly there' 
may be extension from a suppurative pylephlebitis. 

The common duct is greatly dilated and may reach the size of the index 
finger or the thumb; the walls are thickened, and there may be fistulous 
communications with the stomach, colon, or duodenum. The hepatic ducts 
and their extensions in the liver are dilated and contain pus mixed with bile. 
On section of the liver small abscesses are seen, which correspond to the di- 
lated Buppurating ducts. The gall-bladder is usually distended, full of 
pus, and with adhesions to the neighboring parts, or it may have perfo- 
rated . 

Symptoms. — The symptoms of suppurative cholangitis are usually 
very severe. A previous history of gall-stones, the development of a septic 



558 



DISEASES OF THE DIGESTIVE SYSTEM. 



fever, the swelling and tenderness of the liver, the enlargement of the gall- 
bladder, and the lencocytosis are suggestive features. Jaundice is always 
present, but is variable. In some cases it is very intense, in others it is 
slight. There may be very little pain. There is progressive emaciation 
and loss of strength. In a recent case parotitis developed on the left side, 
which subsided without suppuration. 

Ulceration, stricture, perforation, and fistula? of the bile-passages will 
be considered with gall-stones. 

(d) Acute Infectious Cholecystitis. 

Etiology. — Acute inflammation of the gall-bladder is usually due to 
bacterial invasion, with or without the presence of gall-stones. Three vari- 
eties or grades may be recognized: The catarrhal, the suppurative, and the 
phlegmonous. The condition is very serious, difficult to diagnose, often 
fatal, and may require for its relief prompt surgical intervention. The 
cases associated with gall-stones have of course long been recognized, but 
we now know that an acute infection of the gall-bladder leading to suppura- 
tion, gangrene, or perforation is by no means infrequent. For an interest- 
ing series of cases the reader is referred to a paper by Maurice H. Eichard- 
son in the American Journal of the Medical Sciences, 1898, I. In 10 of 
his 59 operations upon the gall-bladder acute cholecystitis was present with- 
out known pre-existing disease! 

Acute non-calculus cholecystitis is a result of bacterial invasion. The 
colon bacillus, the typhoid bacillus, the pneumococcus and staphylococci 
and streptococci have been the organisms most often found. The fre- 
quency of gall-bladder infection in the fevers is a point already referred to, 
particularly in typhoid fever. Two instances of acute cholecystitis have 
occurred within the past year at the Johns Hopkins Hospital in which 
typhoid bacilli were isolated from pure culture, and the Widal reaction was 
present in the patient's blood, without, so far as could be ascertained, any 
history of typhoid fever (see Cushing, Typhoid Cholecystitis, J. H. H. Bul- 
letin, May, 1898). 

Condition of the Gall-bladder.— The organ is usually distended and the 
walls tense. Adhesions may have formed with the colon or the omentum. 
In other instances perforation has taken place and there is a localized ab- 
scess, or in the more fulminant forms general peritonitis. The contents of 
the organ are usually dark in color, muco-purulent, purulent, or hemorrhagic. 
In the cases with acute phlegmonous inflammation there may be a very foul 
odor. As Eichardson remarks, the cystic duct is often found closed even 
when no stone is impacted. It should be borne in mind that in the acutely 
distended gall-bladder the elongation and enlargement may take place 
chiefly upward and inward, toward the foramen of Winslow. 

Symptoms. — Severe paroxysmal pain is, as a rule, the first indication, 
most commonly in the right side of the abdomen in the region of the liver. 
It may be in the epigastrium or low down in the region of the appendix. 
" Nausea, vomiting, rise of pulse and temperature, prostration, distention of 
the abdomen, rigidity, general tenderness becoming localized " usually fol- 



DISEASES 0* THE BILE-PASSAGES AND GALL-BLADDER. 559 



low (Kichardson). In this form, without gall-stones, jaundice is not often 
present. The local tenderness is extreme, but it may be deceptive in its 
situation. Associated probably with the adhesion and inflammatory pro- 
cesses between the gall-bladder and the bowel are the intestinal symptoms, 
and there may be complete stoppage of gas and fasces; indeed, the opera- 
tion for acute obstruction has been performed in several cases. The dis- 
ended gall-bladder may sometimes be felt. 

The diagnosis is by no means easy. The symptoms may not indicate 
the section of the abdomen involved. In two of our cases and in three of 
Kichardson' s appendicitis was diagnosed; in two of his cases acute intes- 
tinal obstruction was suspected. This was the diagnosis in a case of acute 
phlegmonous cholecystitis which I reported in 1881. The history of the 
cases is often a valuable guide. Occurring during the convalescence from 
typhoid fever, after pneumonia, or in a patient with previous cholecystitis, 
such a group of symptoms as mentioned would be highly suggestive. The 
differentiation of the variety of the cholecystitis cannot be made. In the 
acute suppurative and phlegmonous forms the symptoms are usually more 
severe, perforation is very apt to occur, with local or general peritonitis, 
and unless operative measures are undertaken death ensues. 

There is an acute cholecystitis, probably an infective form, in which 
the patient has recurring attacks of pain in the region of the gall-bladder. 
The diagnosis of gall-stones is made, but an operation shows simply an en- 
larged gall-bladder filled with mucus and bile, and the mucous membrane 
perhaps swollen and inflamed. In some of these cases gall-stones may have 
been present and have passed before the operation. 

(e) Cancee or the Bile-passages. 

The subject has been very thoroughly studied of late years by Zenker, 
Musser, Ames, Rolleston, and Kelynack. Females suffer in the propor- 
tion of 3 to 1 (Musser), or 4 to 1 (Ames). In cases of primary cancer of 
the bile-duct, on the other hand, men and women appear to be about 
equally affected. In Musser's series 65 per cent of the cases occurred be- 
tween the ages of forty and seventy. The association of malignant disease 
of the gall-bladder with gall-stones has long been recognized. The fact is 
well put by Kelynack as follows: "While gall-stones are found in from 6 
to 12 per cent of all general cases (that is, coming to autopsy), they occur in 
association with cancer of the gall-bladder in from 90 to 100 per cent." 

The exact nature of the association is not very clear, but it is usually re- 
ga rded as an effect of the chronic irritation. On the other hand, it is urged 
that the presence of the malignant disease may itself favor the production 
of -all-stones. Histologically, " carcinoma of the gall-bladder varies much, 
both in the form of the cells and in their structural arrangement; it may 
be cither columnar or spheroidal-celled" ("Rolleston). The fundus is usu- 
ally first involved in the gall-bladder, and in the ducts the ductus communis 
choledochns. 

When the disease involves the gall-Madder, a tumor can be detected ex- 
tending diagonally downward and inward toward the navel, variable in 
3o 



560 



DISEASES OF THE DIGESTIVE SYSTEM. 



size, occasionally very large, due either to great distention of the gall- 
bladder or to involvement of contiguous parts. It is usually very firm and 
hard. 

Among the important symptoms are jaundice, which was present in 69 
per cent of Mussers cases; pain, often of great severity and paroxysmal in 
character. The pain and tenderness on pressure persist in the intervals 
between the paroxysmal attacks. In one of my three cases, which Ames 
reported, there was a very profound anaemia, but an absence of jaundice 
throughout. Gall-stones were present in two of the cases, and a history of 
gall-stone attacks was obtained from the third. 

Primary malignant disease in the bile-duets is less common, and rarely 
forms tumors that can be felt externally. Kelynack (Medical Chronicle, 
November, 1897) gives very 'fully a number of important points in the dif- 
ferential diagnosis between tumors in the duct and tumors in the gall- 
bladder. There is usually an earl} r , intense, and persistent jaundice. The 
dilated gall-bladder may rupture. At best the diagnosis is very doubtful, 
unless cleared up by an exploratory operation. A very interesting form 
of malignant disease of the ducts is that which involves the diverticulum 
of Vater. Busson has collected eleven cases. A few months ago an elderly 
woman was admitted under my care with jaundice of some months' duration, 
without pain, with progressive emaciation, and a greatly enlarged gall- 
bladder. My colleague, Halsted, operated and found obstruction at the 
orifice of the common duct, He opened the duodenum, removed a cylin- 
drical-celled epithelioma of the ampulla of Vater, and stitched the common 
duct to another portion of the duodenum. The patient made an uninter- 
rupted recovery, and, fourteen weeks after the operation, had gained twen- 
ty-five pounds in weight and passed bile with the faeces. 

(/) Stenosis akd Obstruction of the Bile-ducts. 

Stenosis or complete occlusion may follow ulceration, most commonly 
after the passage of a gall-stone. In these instances the . obstruction is 
usually situated low down in the common duct. Instances are extremely 
rare. Foreign bodies, such as the seeds of various fruits, may enter the 
duct, and occasionally round worms crawl into it. In the Wistar-Horner 
Museum of the University of Pennsylvania there is a remarkable specimen 
showing the common and hepatic ducts enormously distended.* and densely 
packed with a dozen or more lumbricoid worms. Similar specimens exist 
in one of the Paris museums, and at the Eoyal Victoria Hospital, Netley. 
Liver-flukes and echinococci are rare causes of obstruction in man. 

Obstruction by pressure from without is more frequent. Cancer of the 
head of the pancreas, less often a chronic interstitial inflammation, may 
compress the terminal portion of the duct; rarely, cancer of the pylorus. 
Secondary involvement of the lymph-glands of the liver is a common cause 
of occlusion of the duct, and is met with in many cases of cancer of the 
stomach and other abdominal organs. Pare causes of obstruction are aneu- 
rism of a branch of the cceliac axis of the aorta, and pressure of very large 
abdominal tumors. 



CHOLELITHIASIS. 



561 



The symptoms produced are those of chronic obstructive jaundice. At 
first, the liver is usually enlarged, but in chronic cases it may be reduced in 
size, and be found of a deeply bronzed color. The hepatic intermittent fever 
is not often associated with complete occlusion of the duct from any cause, 
but it is most frequently met with in chronic obstruction by gall-stones. 
Permanent occlusion of the duct terminates in death. In a majority of the 
cases the conditions which lead to the obstruction are in themselves fatal. 
The liver, which is not necessarily enlarged, presents a moderate grade of 
cirrhosis. Cases of cicatricial occlusion may last for years. A patient under 
my care, who was permanently jaundiced for nearly three years, had a 
fibroid occlusion of the duct. 

The diagnosis of the nature of the occlusion is often very difficult. A 
history of colic, jaundice of varying intensity, paroxysms of pain, and in- 
termittent fever point to gall-stones. In cancerous obstruction the tumor 
mass can sometimes be felt in the epigastric region. In cases in which 
the lymph-glands in the transverse fissure are cancerous, the primary dis- 
ease may be in the pelvic organs or the rectum, or there may be a limited 
cancer of the stomach, which has not given any symptoms. In these cases 
the examination of the other lymphatic glands may be of value. In a man 
who came uncter observation with a jaundice of seven weeks' duration, 
believed to be catarrhal (as the patient's general condition was good and 
he was not said to have lost flesh), a small nodular mass was detected 
at the navel, which on removal proved to be scirrhus. Involvement of the 
clavicular groups of lymph-glands may also be serviceable in diagnosis. 
The gall-bladder is usually enlarged in obstruction of the common duct, 
except in the cases of gall-stones (Courvoisier's law). Great and progressive 
enlargement of the liver with jaundice and moderate continued fever is more 
commonly met with in cancer. 

Congenital obliteration of the ducts is an interesting condition, of which 
there are some 60 or 70 cases on record. It may occur in several members 
of one family. Spontaneous haemorrhages are frequent, particularly from 
the navel. The subjects may live for three or even eight weeks. For a 
recent careful consideration of the subject, see John Thomson's article in 
Allbutt's System of Medicine. 



VI. CHOLELITHIASIS. 

No chapter in medicine is more interesting than that which deals with the 
question of gall-stones. Few affections present so many points for study — 
chemical, bacteriological, pathological, and clinical. The past few years 
have seen a great advance in our knowledge in two directions: First, as to the 
mode of formation of the stones, and, secondly, as to the surgical treatment 
of the cases. The recent study of the origin of stones dates from Naunyn's 
work in 1891. Marion Sims's suggestion that gall-stones came within the 
sphere of the surgeon has been most fruitful. Lawson Tait, Langenbuch, 
Mayo Robson, Riedel, Kehr, and in this country Keen, Fenger; Murphy, 
Lange, and Ilalsted have not only revolutionized the treatment of chole- 



562 



DISEASES OF THE DIGESTIVE SYSTEM. 



lithiasis, but from their work we physicians have gathered much of the 
greatest moment in symptomatology and diagnosis. 

Origin of Gall-stones. — Two important points with reference to the for- 
mation of calculi in the bile-passages were brought out by Naunyn: (a) 
The origin of the cholesterin of the bile, as well as of the lime salts from the 
mucous membrane of the biliary passages, particularly when inflamed; and 
(b) the remarkable association of micro-organisms with gall-stones. It is 
stated that Bristowe first noticed the origin of cholesterin in the gall-blad- 
der itself, but Naunyn's observations showed that both the cholesterin and 
the lime were in great part a production of the mucosa of the gall-bladder 
and of the bile-ducts, particularly when in a condition of catarrhal inflam- 
mation excited by the presence of microbes. According to the views of this 
author, the lithogenous catarrh (which, by the way, is quite an old idea) 
modifies materially the chemical constitution of the bile and favors the de- 
position about epithelial debris and bacteria of the insoluble salts of lime 
in combination with the bilirubin. Welch and others have demonstrated 
the presence of micro-organisms in the centre of gall-stones. Three addi- 
tional points of interest may be referred to: 

First, the demonstration that the gall-bladder is a peculiarly favorable 
habitat for micro-organisms. The colon bacilli, staphylococci, streptococci, 
pneumococci, and the typhoid bacilli have all been found here under varying 
conditions of the bile. A remarkable fact is the length of time that they 
may live in the gall-bladder, as was first demonstrated by Blachstein in 
Welch's laboratory. The typhoid bacillus has been isolated in pure culture 
seven years after an attack. 

Secondly, the experimental production of gall-stones has been success- 
fully accomplished by Gilbert and Fournier by injecting micro-organisms 
into the gall-bladder of animals. 

Thirdly, the association of gall-stones with the specific fevers. Bern- 
heim, in 1889, first called attention to the frequency of gall-stone attacks 
after typhoid. Since that time Dufort has collected a series of cases, and 
Chiari, Mason, and Camac have called attention to the great frequency of 
gall-bladder complications during and after this disease. 

While it is probable that a lithogenous catarrh, induced by micro-organ- 
isms, is the most important single factor, there are other accessory causes of 
great moment. 

Age. — Nearly 50 per cent of all the cases occur in persons above forty 
years of age. They are rare under twenty-five. They have been met with 
in the new-born, and in infants (John Thomson). 

Sex. — Three fourths of the cases occur in women. Pregnancy has an 
important influence. Naunyn states that 90 per cent of women with 
gall-stones have borne children. 

All conditions which favor stagnation of bile in the gall-bladder predis- 
pose to the formation of stones. Among these may be mentioned corset- 
wearing, enteroptosis, nephroptosis, and occupations requiring a " leaning 
forward " position. Lack of exercise, sedentary occupations, particularly 
when combined with over-indulgence in food, constipation, depressing men- 
tal emotions are also to be regarded as favoring circumstances. The belief 



CHOLELITHIASIS. 



563 



prevailed formerly that there was a lithiac diathesis closely allied to that 
of gout. 

Physical Characters of Gall-stones. — They may he single, in which case 
the stone is usually ovoid and may attain a very large size. Instances are 
on record of gall-stones measuring more than 5 inches in length. They may 
be extremely numerous, ranging from a score to several hundreds or even 
several thousands, in which case the stones are very small. When moderately 
numerous, they show signs of mutual pressure and have a polygonal form, 
with smooth facets; occasionally, however, five or six gall-stones of medium 
size are met with in the bladder which are round or ovoid and without 
facets. They are sometimes mulberry-shaped and very dark, consisting 
largely of bile-pigments. Again there are small, black calculi, rough and 
irregular in shape, and varying in size from grains of sand to small shot. 
These are sometimes known as gall-sand. On section, a calculus contains 
a nucleus, which consists of bile-pigment, rarely a foreign body. The 
greater portion of the stone is made up of cholesterin, which may form 
the entire calculus and is arranged in concentric laminae showing also radi- 
ating lines. Salts of lime and magnesia, bile acids, fatty acids, and traces 
of iron and copper are also found in them. A majority of gall-stones con- 
sist of from 70 to 80 per cent of cholesterin, in either the amorphous or the 
crystalline form. As above stated, it is sometimes pure, but more commonly 
it is mixed with the bile-pigment. The outer layer of the stone is usually 
harder and brownish in color, and contains a larger proportion of lime salts. 

The Seat of Formation. — Within the liver itself calculi are occasionally 
found, but are here usually small and not abundant, and in the form of 
ovoid, greenish-black grains. A large majority of all calculi are formed 
within the gall-bladder. The stones in the larger ducts have usually had 
their origin in the gall-bladder. 

Symptoms. — In a majority of the cases, gall-stones cause no symp- 
toms. The gall-bladder will tolerate the presence of large numbers for an 
indefinite period of time, and post-mortem examinations show that they 
are present in 25 per cent of all women over sixty years of age (Naunyn). 

The French writers have suggested a useful division, dealing with the 
main symptoms of cholelithiasis, into (1) the aseptic, mechanical accidents 
in consequence of migration of the stone or of obstruction, either in the 
ducts or in the intestines; (2) the septic, infectious accidents, either local 
(the angiocholitis and cholecystitis with empyema of the gall-bladder, and 
the fistulae and abscess of the liver and infection of the neighboring parts) 
or general, the biliary fever and the secondary visceral lesions. 

It will be better, perhaps, to consider cholelithiasis under the following 
headings: The symptoms produced by the passage of a stone through the 
ducts — biliary colic; the effects of permanent plugging of the cystic duct; 
of the stone in the common duct; and the more remote effects, due to 
ulceration, perforation, and the establishment of fistula}. 

1. Biliary Colic. — Gall-stones may become engaged in the cystic or the 
common duet without producing pain or severe symptoms. More com- 
monly the passage of a stone excites the violent symptoms known as biliary 
colic. The attack sets in abruptly with agonizing pain in the right hypo- 



-564 



DISEASES OF THE DIGESTIVE SYSTEM. 



chondriac region, which radiates to the shoulder, or is very intense in the 
epigastric and in the lower thoracic regions. It is often associated with a 
rigor and a rise in temperature from 102° to 103°. The pain is usually so 
intense that the patient rolls about in agony. There are vomiting, pro- 
fuse sweating, and great depression of the circulation. There may be 
marked tenderness in the region of the liver, which may be enlarged, and 
the gall-bladder may become palpable and very tender. In other cases the 
fever is more marked. The spleen is enlarged (Naunyn) and the urine con- 
tains albumin with red blood-corpuscles. Ortner holds that cholecystitis 
acuta, occurring in connection with gall-stones, is a septic (bacterial) in- 
fection of the bile-passages. The symptoms of acute infectious cholecystitis 
and those of what we call gall-stone colic are very similar, and surgeons have 
frequently performed cholecystotomy for the former condition, believing 
calculi were present. In a large number of the cases jaundice develops, but 
it is not a necessary symptom. Of course it does not occur during the pas- 
sage of the stone through the cystic duct, but only when it becomes 
lodged in the common duct. The pain is due (a) to the slow progress in 
the cystic duct, in which the stone takes a rotary course owing to the ar- 
rangement of the Heisterian valve; (b) to the acute inflammation which 
usually accompanies an attack; and (c) to the stretching and distention of 
the gall-bladder by retained secretions. 

The attack varies in duration. It may last for a few hours, several 
days, or even a week or more. If the stone becomes impacted in the orifice 
of the common duct, the jaundice becomes intense; much more commonly 
it is a slight transient icterus. The attack of colic may be repeated at in- 
tervals for some time, but finally the stone passes and the symptoms rapidly 
disappear. 

Occasionally accidents occur, such as rupture of the duct with fatal 
peritonitis. Fatal syncope during an attack, and the occurrence of re- 
peated convulsive seizures have come under my observation. These are, 
however, rare events. Palpitation and distress about the heart may be 
present, and occasionally a mitral murmur develops during the paroxysm; 
but the cardiac conditions described by some writers as coming on acutely 
in biliary colic are possibly pre-existent in these patients. 

The diagnosis of acute hepatic colic is generally easy. The pain is in 
the upper abdominal and thoracic regions, whereas the pain in nephritic 
colic is in the lower abdomen. A chill, with fever, is much more frequent 
in biliary colic than in gastralgia, with which it is liable, at times, to be 
confounded. A history of previous attacks is an important guide, and the 
occurrence of jaundice, however slight, determines the diagnosis. To look 
for the gall-stones, the stools should be thoroughly mixed with water and 
carefully filtered through a narrow-meshed sieve. Pseudo-biliary colic is not 
infrequently met with in nervous women, and the diagnosis of gall-stones 
made. This nervous hepatic colic may be periodical; the pain may be in the 
right side and radiating; sometimes associated with other nervous phenom- 
ena, often excited by emotion, tire, or excesses. The liver may be tender, 
but there are neither icterus nor inflammatory conditions. The combina- 
tion of colic and jaundice, so distinctive of gall-stones, is not always present. 



CHOLELITHIASIS. 



565 



The pains may be not colicky, but more constant and dragging in charac- 
ter. Of 50 cases operated upon by Kiedel, 10 had not had colic, only 14 
presented a gall-bladder tumor, while a majority had not had jaundice. A 
remarkable xanthoma of the bile-passages has been found in association with 
hepatic colic. I have already spoken of the diagnosis of acute cholecystitis 
from appendicitis and obstruction of the bowels. Eecurring attacks of pain 
in the region of the liver may follow adhesions between the gall-bladder 
and adjacent parts. 

2. Obstruction of the Cystic Duct. — The effects may be thus enumer- 
ated: 

(a) Dilatation of the gall-bladder — hydrops vesicae felleae. In acute ob- 
struction the contents are bile mixed with much mucous or muco-purulent 
material. In chronic obstruction the bile is replaced by a clear fluid mucus. 
This is an important point in diagnosis, particularly as a dropsical gall- 
bladder may form a very large tumor. The reaction is not always con- 
stant. It is either alkaline or neutral; the consistence is thin and mucoid. 
Albumin is usually present. A dilated gall-bladder may reach an enormous 
size, and in one instance Tait found it occupying the greater part of the 
abdomen. In such cases, as is not unnatural, it has been mistaken for an 
ovarian tumor. I have described a case in which it was attached to the 
right broad ligament. The dilated gall-bladder can usually be felt below 
the edge of the liver, and in many instances it has a characteristic outline 
like a gourd. An enlarged and relaxed organ may not be palpable, and in 
acute cases the distention may be upward toward the hilus of the liver. 
The dilated gall-bladder usually projects directly downward, rarely to one 
side or the other, though occasionally toward the middle line. It may 
reach below the navel, and in persons with thin walls the outline can be 
accurately defined. Eiedel has called attention to a tongue-like projection 
of the anterior margin of the right lobe in connection with enlarged gall- 
bladder. It is to be remembered that distention of the gall-bladder may 
occur without jaundice; indeed, the greatest enlargement has been met with 
in such cases. 

Gall-stone crepitus may be felt when the bladder is very full of stones 
and its walls not very tense. It is rarely well felt unless the abdominal walls 
are much relaxed. It may be found in patients who have never had any 
symptoms cf cholelithiasis. 

(&) Acute cholecystitis. The simple form is common, and to it arc due 
probably very many of the symptoms of the gall-stone attack. Phleg- 
monous cholecystitis is rare; only seven instances are found in the enor- 
mous statistics of Courvoisier. It is, however, much more common than 
these figures indicate. Perforation may occur with fatal peritonitis. 

(c) Suppurative cholecystitis, empyema of the gall-bladder, is much 
more common, and in the great majority of cases is associated witli gall- 
stones — 41 in 55 cases (Courvoisier). There may be enormous dilatation, 
and over a litre of pus has been found. Perforation and the formation of 
abscesses in the neighborhood are not uncommon. 

(d) Calcification of the gall-bladder is commonly a termination of the 
previous condition. There are two separate forms: incrustation of the 



566 



DISEASES OF THE DIGESTIVE SYSTEM. 



mucosa with lime salts and the true infiltration of the wall with lime, the 
so-called ossification. A remarkable example of the latter, sent to me by 
Groves, of Carp, is now in the Me Gill Medical Museum. 

(e) Atrophy of the gall-bladder. This is by no means uncommon. The 
organ shrinks into a small fibroid mass, not larger, perhaps, than a good- 
sized pea or walnut, or even has the form of a narrow fibrous string; more 
commonly the gall-bladder tightly embraces a stone. This condition is 
usually preceded by hydrops of the bladder. 

Occasionally the gall-bladder presents diverticula, which may be cut off 
from the main portion, and usually contain calculi. 

(3) Obstruction of the Common Duct. — There may be a single stone 
tightly wedged in the duct in any part of its course, or a series of stones, 
sometimes extending into both hepatic and cystic ducts, or a stone lies in 
the diverticulum of Vater. There are three groups of cases: (a) In rare 
instances a stone tightly corks the common duct, causing permanent occlu- 
sion; or it may partly rest in the cystic duct, and may have caused thicken- 
ing of the junction of the ducts; or a big stone may compress the hepatic 
or upper part of the common duct. The jaundice is deep and enduring, 
and there are no septic features. The pains, the previous attacks of colic, 
and the absence of enlarged gall-bladder help to separate the condition from 
obstruction by new growths, although it cannot be differentiated with cer- 
tainty. The ducts are usually much dilated and everywhere contain a clear 
mucoid fluid. 

(b) Incomplete obstruction, with infective cholangitis. 

There may be a series of stones in the common duct, a single stone which 
is freely movable, or a stone (ball-valve stone) in the diverticulum of Vater. 
These conditions may be met with at autopsy, without the subjects having 
had symptoms pointing to gall-stones; but in a majority of cases there are 
very characteristic features. 

The common duct may be as large as the thumb; the hepatic duct and 
its branches through the liver may be greatly dilated, and the distention may 
even be apparent beneath the liver capsule. Great enlargement of the 
gall-bladder is rare. The mucous membrane of the duets is usually smooth 
and clear, and the contents consist of a thin, slightly turbid bile-stained 
mucus. 

Naunyn has given the following as the distinguishing signs of stone in 
the common duct: " (1) The continuous or occasional presence of bile in 
the faeces; (2) distinct variations in the intensity of the jaundice; (3) 
normal size or only slight enlargement of the liver; (') absence of disten- 
tion of the gall-bladder; (5) enlargement of the spleen; (6) absence of 
ascites; (7) presence of febrile disturbance; and (8) duration of the jaun- 
dice for more than a year/' 

In connection with the ball-valve stone, which is most commonly found 
in the diverticulum of Vater, though it may be in the common duct itself, 
I have tried to separate a special symptom group: (a) Ague-like paroxysms, 
chills, fever, and sweating; the hepatic intermittent fever of Charcot; (b) 
jaundice of varying intensity, which persists for months or even years, and 
deepens after each paroxysm; (c) at the time of the paroxysms, pains in the 



CHOLELITHIASIS. 



region of the liver with gastric disturbance. These symptoms may continue 
on and off for three or four years, without the development of suppurative 
cholangitis. In one of my cases the jaundice and recurring hepatic inter- 
mittent fever existed from July, 1879, until August, 1882; the patient re- 
covered and still lives. The condition has lasted from eight months to 
three years. The rigors are of intense severity, and the temperature rises 
to 103° or 105°. The chills may recur daily for weeks, and present a tertian 
or quartan type, so that they are often attributed to malaria, with which, 
however, they have no connection. The jaundice is variable, and deepens 
after each paroxysm. The itching may be most intense. Pain, which is 
sometimes severe and colicky, does not always occur. There may be marked 
vomiting and nausea. As a rule there is no progressive deterioration of 
health. In the intervals between the attacks the temperature is normal. 

The clinical history and the post-mortem examinations in my cases show 
conclusively that this condition may persist for years without a trace of 
suppuration within the ducts. There must, however, be an infection, such 
as may exist for years in the gall-bladder, without causing suppuration. 
It is probable that the toxic symptoms only develop when a certain grade 
of tension is reached. 

An interesting and valuable diagnostic point is the absence of dilatation 
of the gall-bladder in cases of obstruction from stone — Courvoisier's rule. 
Ecklin, who has recently reviewed this point, finds that of 172 cases of ob- 
struction of the common duct by calculus in 34 the gall-bladder was normal, 
in 110 it was contracted, and in 28 it was dilated. Of 139 cases of occlusion 
of the common duct from other causes the gall-bladder was normal in 9, 
shrunken in 9, and dilated in 121. 

(c) Incomplete obstruction, with suppurative cholangitis. 

AYhen suppurative cholangitis exists the mucosa is thickened, often 
eroded or ulcerated; there may be extensive suppuration in the ducts 
throughout the liver, and even empyema of the gall-bladder. Occasionally 
the suppuration extends beyond the ducts, and there is localized liver ab- 
scess, or there is perforation of the gall-bladder with the formation of ab- 
scess between the liver and stomach. 

Clinically it is characterized by a fever which may be intermittent, but 
more commonly is remittent and without prolonged intervals of apyrexia. 
The jaundice is rarely so intense, nor do we see the deepening of the color 
after the paroxysms. There is usually greater enlargement of the liver 
and tenderness and more definite signs of septicaemia. The cases run a 
shorter course, and recovery never takes place. 

(4) The More Remote Effects of Gall-stones.— (a) Biliary Fistula?. 
These are not uncommon. There may, for instance, be abnormal commu- 
nication between the gall-bladder and the hepatic duct or the gall-bladder 
and a cavity in the liver itself. More rarely perforation occurs between 
Hi' common duct and the portal vein. Of this there arc at least four in- 
stances on record, among them the celebrated case of Ignatius Loyola. 
Perforation into the abdominal cavity is not uncommon; 119 cases exist 
in the literature (Courvoisicr), in 70 of which the rupture occurred directly 
into the peritoneal cavity; in 49 there was an encapsulated abscess. Per- 



568 



DISEASES OF THE DIGESTIVE SYSTEM. 



foration may take place from an intrahepatic branch or from the hepatic, 
common, or cystic ducts. Perforation from the gall-bladder is the most 
common. 

Fistulous communications between the bile-passages and the gastroin- 
testinal canal are frequent. Openings into the stomach are rare. Between 
the duodenum and bile-passages they are much more common. Cour- 
voisier has collected 10 instances of communication between the ductus 
communis and the duodenum, and 73 cases between the gall-bladder and 
the duodenum. Communication with the ileum and jejunum is extremely 
rare. Of fistulous opening into the colon 39 cases are on record. These 
communications can rarely be diagnosed; they may be present without any 
symptoms whatever. It is probably by ulceration into the duodenum or 
colon that the large gall-stones escape. 

Occasionally the urinary passages may be opened into and the stones 
may be found in the bladder. Many instances are on record of fistula? be- 
tween the bile-passages and the lungs. Courvoisier has collected 24 cases, 
to which list J. E. Graham has added 10, including 2 cases of his own. 
(Trans, of Assoc. of Am. Physicians, xiii.) Bile may be coughed up with 
the expectoration, sometimes in considerable quantities. 

Of all fistulous communications the external or cutaneous is the most 
common. Courvoisier's statistics number 184 cases, in 50 per cent of 
which the perforation took place in the right hypochondrium; in 29 per 
cent in the region of the navel. The number of stones discharged varied 
from one or two to many hundreds. Eecovery took place in 78 cases; some 
with, some without operation. 

(b) Obstruction of the Bowel by Gall-stones. — Eeference has already been 
made to this; its frequency appears from the fact that of 295 cases of 
obstruction, occurring during eight years, analyzed by Fitz, 23 were by 
gall-stone. Courvoisier's statistics give a total number of 131 cases, in 6 
of which the calculi had a peculiar situation, as in a diverticulum or in the 
appendix. Of the remaining 125 cases, in 70 the stone was spontaneously 
passed, usually with severe symptoms. The post-mortem reports show that 
in some of these cases even very large stones have passed per viam naturalem, 
as the gall-duct has been enormously distended, its orifice admitting the 
finger freely. This, however, is extremely rare. The stones have been 
found most commonly in the ileum. 

Treatment of Gall-stones and their Effects. — In an attack of 
biliary colic the patient should be kept under morphia, given hypodermic- 
ally, in quarter-grain doses. In an agonizing paroxysm it is well to give 
a whiff or two of chloroform until the morphia has had time to act. Great 
relief is experienced from the hot bath and from fomentations in the region 
of the liver. The patient should be given laxatives and should drink co- 
piously of alkaline mineral waters. Olive oil has proved useless in my 
hands. When taken in large quantities, fatty concretions are passed with 
the stools, which have been regarded as calculi; and concretions due to 
eating pears have been also mistaken, particularly when associated with 
colic attacks. Since the days of Durande, whose mixture of ether and 
turpentine is still largely used in France, various remedies have been ad- 



THE CIREHOSES OF THE LIVER. 



569 



vised to dissolve the stones within the gall-bladder, none of which are 
efficacious. 

The diet should be regulated, the patient should take regular exercise 
and avoid, as much as possible, the starchy and saccharine foods. The 
soda salts recommended by Prout are believed to prevent the concentra- 
tion of the bile and the formation of gall-stones. Either the sulphate or 
the phosphate may be taken in doses of from 1 to 2 drachms daily. 
For the intolerable itching McCall Anderson's dusting powder may be used: 
starch, an ounce; camphor, a drachm and a half; and oxide of zinc, half 
an ounce. Some of this should be finely dusted over the skin with a powder- 
puff. Powdering with starch, strong alkaline baths (hot), pilocarpin hypo- 
dermically (gr. and antipyrin (gr. viij), may be tried. Ichthyol and 

lanolin ointment sometimes gives relief. 

Exploratory puncture, as practised by the elder Pepper, in 1857, in a 
case of empyema of the gall-bladder, and by Bartholow in 1878 is not 
now often done. Aspiration is usually a safe procedure, though a fatal 
result has followed. 

The surgical treatment of gall-stones has of late years made rapid 
progress. The operation of cholecystotomy, or opening the gall-bladder 
and removing the stones, which was advised by Sims, has been remark- 
ably successful. The removal of the gall-bladder, cholecystectomy, has also 
been practised with success. The indications for operation are: (a) Ee- 
peated attacks of gall-stone colic. The operation is now attended with such 
slight risk that the patient is much safer in the hands of a surgeon than 
when left to Nature, with the feeble assistance of drugs and mineral waters. 
(b) The presence of a distended gall-bladder, associated with attacks of pain 
or with fever, (c) When a gall-stone is permanently lodged in the common 
duct, and the group of symptoms above described are present, the ques- 
tion, then, of advising operation depends largely upon the personal methods 
and success of the surgeon who is available. The operation, necessarily 
much more serious and difficult than that upon the gall-bladder, is now 
remarkably successful even in desperate cases of years' duration. 



VII. THE C1RRHOSES OF THE LIVER. 

General Considerations.— The many forms of cirrhoses of the 
liver have one feature in common — an increase in the connective tissue of * 
the organ. In fact, we use the term cirrhosis (by which Lannec character- 
ized the tawny, yellow color of the common atrophic form) to indicate simi- 
lar changes in other organs. 

The cirrhoses may be classified, etiologically, according to the supposed 
causation; anatomically, according to the structure primarily involved; or 
clinically, according to certain special symptoms. 

Etiological Classification.— 1. Toxic Cirrhoses.— Alcohol is the chief 
en use of cirrhosis of the liver. Other poisons, such as lead and the toxic 
products of faulty metabolism in gout, diabetes, rickets, and indigestion, 
play a minor role. 



570 



DISEASES OF THE DIGESTIVE SYSTEM. 



2. Infectious CirrJioses. — With many ^ of the specific fevers necrotic 
changes occur in the liver which, when widespread, may be followed by 
cirrhosis. Possibly the hypertrophic cirrhosis of Hanot and other forms 
met with in early life are due to infection. The malarial cirrhosis is a well- 
recognized variety. The syphilitic poison produces a very characteristic 
form. 

3. Cirrhosis from chronic congestion of the Mood-vessels in heart-disease 
— the cardiac liver. 

4. Cirrhosis from chronic obstruction of the bile-ducts, a form of very 
slight clinical interest. In anthracosis the carbon pigment may reach the 
liver in large quantities and be deposited in the connective tissue about the 
portal canal, leading to cirrhosis (Welch). 

Anatomical Classification.— 1. Vascular cirrhoses, in which the new 
growth of connective tissue has its starting point about the finer branches 
the portal or hepatic veins. 

2. Biliary cirrhoses, in which the process is supposed to begin about 
the finer bile-ducts, as in the hypertrophic cirrhosis of Hanot and in the 
form from obstruction of the larger ducts. 

3. Capsular cirrhoses, a perihepatitis leading to great thickening of the 
capsule and reduction in the volume of the liver. 

Clinical Classification. — For practical purposes we may recognize the fol- 
lowing varieties of cirrhosis of the liver: 

1. The alcoholic cirrhosis of Laennec, including with this the fatty cir- 
rhotic liver. 

2. The hypertrophic cirrhosis of Hanot. 

3. Syphilitic cirrhosis. 

4. Capsular cirrhosis — chronic perihepatitis. 

Other forms, of slight clinical interest, are considered elsewhere under 
diabetes, malaria, tuberculosis, and heart-disease. The cirrhosis from ma- 
laria, upon which the French writers lay so much stress (one describes thir- 
teen varieties!), is excessively rare. In our large experience with malaria 
during the past nine years not a single case of advanced cirrhosis due to 
this cause has been seen in the wards or autopsy-room of the Johns Hop- 
kins Hospital. 

I. ALCOHOLIC CIRRHOSIS. 

Etiology. — The disease occurs most frequently in middle-aged males 
* who have been addicted to drink. Whiskey, gin, and brandy are more po- 
tent to cause cirrhoses than beer. It is more common in countries in which 
strong spirits are used than in those in which malt liquors are taken. Among 
1,000 autopsies in my colleague Welch's department of the Johns Hopkins 
Hospital there were 63 cases of small atrophic liver, and 8 cases of the fatty 
cirrhotic organ. Lancereaux claims that the vin ordinaire of France is a 
common cause of cirrhosis. Of 210 cases, excess in wine alone was present 
in 68 cases. He thinks it is the sulphate of potash in the plaster of Paris 
used to give the " dry " flavor which damages the lrver. 

Cirrhosis of the liver in young children is not very rare. Palmer How- 
ard collected 63 cases, to which Hatfield added 93. In a certain num- 



THE CIRRHOSES OF THE LIVER. 



571 



ber of the cases there is an alcoholic history, in others syphilis has been pres- 
ent, while a third group, due to the poisons of the infections diseases, em- 
braces a certain number of the cases of Hanot's hypertrophic cirrhosis. 

Morbid Anatomy. — Practically on the post-mortem table we see 
alcoholic cirrhosis in two well-characterized forms: 

The Atrophic Cirrhosis of Laennec. — The organ is greatly reduced in 
size and may be deformed. The weight is sometimes not more than a 
pound or a pound and a half. It presents numerous granulations on the 
surface; is firm, hard, and cuts with great resistance. The substance is 
seen to be made up of greenish-yellow islands, surrounded by grayish-white 
connective tissue. This yellow appearance of the liver induced Laennec to 
give to the condition the name of cirrhosis. 

The Fatty Cirrhotic Liver. — Even in the atrophic form the fat is in- 
creased, but in typical examples of this variety the organ is not reduced in 
size, but is enlarged, smooth or very slightly granular, anaamic, yellowish 
white in color, and resembles an ordinary fatty liver. It is, however, firm, 
cuts with resistance, and microscopically shows a great increase in the con- 
nective tissue. This form occurs most frequently in beer-drinkers. 

The two essential elements in cirrhosis are destruction of liver-cells and 
obstruction to the portal circulation. 

In an autopsy on a case of atrophic cirrhosis the peritonaeum is usually 
found to contain a large quantity of fluid, the membrane is opaque, and 
there is chronic catarrh of the stomach and of the small intestines. The 
spleen is enlarged, in part, at least, from the chronic congestion, possibly 
due in part to a " vital reaction," to a toxic influence (Parkes AYeber). The 
kidneys are sometimes cirrhotic, the bases of the lungs may be much com- 
pressed by the ascitic fluid, the heart often shows marked degeneration, 
and arterio-sclerosis is usually present. A remarkable feature is the asso- 
ciation of acute tuberculosis with cirrhosis. In seven cases of my series 
the patients died with either acute tuberculous peritonitis or acute tuber- 
culous pleurisy. Pitt states that 22 J per cent of the cases of cirrhosis dying 
in Guy's Hospital during twelve years had acute tuberculosis. Of 121 
autopsies at the Manchester Royal Infirmary in cirrhosis, about 23 per cent 
gave evidence of tuberculous infection. Twelve of these had tuberculosis 
of the peritonaeum, and 12 died directly from the tuberculous infection 
(Kelynack). 

The compensatory circulation is usually readily demonstrated. It is 
carried out by the following set of vessels: (1) The accessory portal system 
of Sappey, of which important branches pass in the round and suspensory 
ligaments and unite with the epigastric and mammary systems. These ves- 
sels are numerous and small. Occasionally a large single vein, which may 
attain the size of the little finger, passes from the hilus of the liver, follows 
the round ligament, and joins the epigastric veins at the navel. Although 
this has the position of the umbilical vein, it is usually, as Sappey showed, 
a para-umbilical vein — that is, an enlarged vein by the side of the obliter- 
ated umbilical vessel. There may be produced about the navel a large 
bunch of varices, the so-called caput Medusae. Other branches of this 
system occur in the gastro-epiploic omentum, about the gall-bladder, and, 



572 



DISEASES OF THE DIGESTIVE SYSTEM. 



most important of all, in the suspensory ligament. These latter form large 
branches, which anastomose freely with the diaphragmatic veins, and so 
nnite with the vena azygos. (2) By the anastomosis between the oesoph- 
ageal and gastric veins. The veins at the lower end of the oesophagus may 
be enormously enlarged, producing varices which project on the mucous 
membrane. (3) The communications between the hemorrhoidal and the in- 
ferior mesenteric veins. The freedom of communication in this direction 
is very variable, and in some instances the haemorrhoidal veins are not much 
enlarged. (4) The veins of Eetzius, which unite the radicles of the portal 
branches in the intestines and mesentery with the inferior vena cava and 
its branches. To this system belong the whole group of retroperitoneal 
veins, which are in most instances enormously enlarged, particularly about 
the kidneys, and which serve to carry off a considerable proportion of the 
portal blood. 

Symptoms. — The most extreme grade of atrophic cirrhosis may exist 
without symptoms. So long as the compensatory circulation is maintained 
the patient may suffer little or no inconvenience. The remarkable effi- 
ciency of this collateral circulation is well seen in those rare instances of 
permanent obliteration of the portal vein. The symptoms may be divided 
into two groups — obstructive and toxic. 

Obstructive. — The overfilling of the blood-vessels of the stomach and 
intestine lead to chronic catarrh, and the patients suffer with nausea and 
vomiting, particularly in the morning; the tongue is furred and the bowels 
are irregular. Haemorrhage from the stomach may be an early symptom; 
it is often profuse and liable to recur. It seldom proves fatal. The amount 
vomited may be remarkable, as in a case already referred to, in which ten 
pounds were ejected in seven days. Following the haematemesis melaena 
is common; but haemorrhages from the bowels may occur for several years 
without haematemesis. The bleeding very often comes from the oesopha- 
geal varices already described (p. 459). Very frequently epistaxis occurs. 
Enlargement of the spleen may, as Parkes Weber suggests, be due to a 
toxemia. The organ can usually be felt. Evidences of the establishment 
of the collateral circulation are seen in the enlarged epigastric and mam- 
mary veins, more rarely in the presence of the caput Medusae and in the 
development of haemorrhoids. The distended venules in the lower thoracic 
zone along the line of attachment of the diaphragm are not specially 
marked in cirrhosis. The most striking feature of failure in the com- 
pensatory circulation is ascites, the effusion of serous fluid into the peri- 
toneal cavity. The conditions under which this occurs are still obscure. 
The abdomen gradually distends, may reach a large size, and contain as 
much as 15 or 20 litres. (Edema of the feet may precede or develop with 
the ascites. The dropsy is rarely general. Spider angiomata are common. 

Jaundice is usually slight, and was present in only 35 of 130 cases of 
cirrhosis reported by Fagge. The skin has frequently a sallow, slightly 
icteroid tint. The urine is often reduced in amount, contains urates in 
abundance, often a slight amount of albumin, and, if jaundice is intense, 
tube-casts. The disease may be afebrile throughout, but in many cases, 
as shown by Carringten, there is slight fever, from 100° to 102.5°. 



THE CIRRHOSES OF THE LIVER. 



573 



Examination at an early stage of the disease may show an enlarged and 
painful liver. Dreschfeld, Foxwell, and others in England have of late 
years called particular attention to the fact that in very many of the cases 
of alcoholic cirrhosis the organ is " enlarged at all stages of the disease, and 
that whether enlarged or contracted the clinical symptoms and course are 
much the same " (Foxwell). The patient may first come under observa- 
tion for dyspepsia, haematemesis, slight jaundice, or nervous symptoms. 
Later in the disease, the patient has an unmistakable hepatic facies; he is 
thin, the eyes are sunken, the conjunctivae watery, the nose and cheeks 
show distended venules, and the complexion is muddy or icteroid. On the 
enlarged abdomen the vessels are distended, and a bunch of dilated veins 
may surround the navel. When much fluid is in the peritonaeum it is 
impossible to make a satisfactory examination, but after withdrawal the 
area of liver dulness is found to be diminished, particularly in the middle 
line, and on deep pressure the edge of the liver can be detected, and occa- 
^ sionally the hard, firm, and even granular surface. The spleen can be felt 
in the left hypochondriac region. Examination of the anus may reveal 
the presence of haemorrhoids. 

Toxic Symptoms. — At any stage of atrophic cirrhosis the patient may 
develop cerebral symptoms, either a noisy, joyous delirium, or stupor, 
coma, or even convulsions. The condition is not infrequently mistaken for 
uraemia. The nature of the toxic agent is not yet settled. The symptoms 
may develop without jaundice, and cannot be attributed to cholaemia, and 
they may come on in hospital when the patient has not had alcohol for 
weeks. 

The fatty cirrhotic liver may produce symptoms similar to those of the 
atrophic form, but it more frequently is latent and is found accidentally in 
topers who have died from various diseases. The greater number of the cases 
clinically diagnosed as cirrhosis with enlargement come in this division. 

Diagnosis. — With ascites, a well-marked history of alcoholism, the 
hepatic facies, and haemorrhage from the stomach or bowels, the diagnosis 
is rarely doubtful. If, after withdrawal of the fluid, the spleen is found 
to be enlarged and the liver either not palpable or, if it is enlarged, hard 
and regular, the probabilities in favor of cirrhosis are very great. In the 
early stages of the disease, when the liver is increased in size, it may be 
impossible to say whether it is a cirrhotic or a fatty liver. The differential 
diagnosis between common and syphilitic cirrhosis can sometimes be made. 
A marked history of syphilis or the existence of other syphilitic lesions, with 
great irregularity in the surface or at the edge of the liver, are the points 
in favor of the latter. Thrombosis or obliteration of the portal vein can 
rarely be differentiated. In a case of fibroid transformation of the portal 
vein which came under my observation, the collateral circulation had been 
established for years, and the symptoms were simply those of extreme por- 
ta] obstruction, snch as occur in cirrhosis. Thrombosis of the portal vein 
is frequent in cirrhosis and may be characterized by a rapidly developing 
ascites. 

Prognosis.— The prognosis is bad. Wl icn the collateral circulation 
is fully established the patient may have no symptoms whatever. Three 



574 



DISEASES OF THE DIGESTIVE SYSTEM. 



cases of advanced atrophic cirrhosis have died under my observation of 
other affections without presenting during life any symptoms pointing to 
disease of the liver. There are instances, too, of enlargement of the liver, 
slight jaundice, cerebral symptoms, and even hasmateniesis, in which the 
liver becomes reduced in size, the symptoms disappear, and the patient may 
live in comparative comfort for many years. There are cases, too, possibly 
syphilitic, in which, after one or two tappings, the symptoms have disap- 
peared and the patients have apparently recovered. Ascites is a very serious 
event in ordinary cirrhosis. Of 34 cases with ascites 10 died before tap- 
ping was necessary; 14 were tapped, and the average duration of life after 
the swelling was first noticed was only eight weeks; of 10 cases the diag- 
nosis was wrong in 4, and in the remaining 6, who were tapped oftener 
than once, chronic peritonitis and perihepatitis were present (Hale White). 

II. HYPERTROPHIC CIRRHOSIS (Hanoi). 

This well-characterized form was first described by Eequin in 1846, 
but our accurate knowledge of the condition dates from the work of 
the lamented Hanot (1875), whose name in France it bears — maladie de 
Hanoi. 

Cirrhosis with enlargement occurs in the early stage of atrophic cirrho- 
sis; there is an enlarged fatty and cirrhotic liver of alcoholics, a pigmentary 
form in diabetes has been described, and in association with syphilis the 
organ is often very large. The hypertrophic cirrhosis of Hanot is easily 
distinguished from these forms. 

Etiology. — Males are more often affected than females — in 22 
of Schachmann's 26 cases. The subjects are young; some of the cases 
in children probably belong to this form. Of four recent cases under my 
care the ages were from twenty to thirty-five. Two were brothers. Alco- 
hol plays a minor part. Not one of the four cases referred to had been a 
heavy drinker. The absence of all known etiological factors is a remark- 
able feature in a majority of the cases. 

Morbid Anatomy. — The organ is enlarged, weighing from 2,000 to 
4,000 grammes. The form is maintained, the surface is smooth, or presents 
small granulations; the color in advanced cases is of a dark olive green; 
the consistence is greatly increased. The section is uniform, greenish yel- 
low in color, and the liver lobules may be seen separated by connective 
tissue. The bile-passages present nothing abnormal. In a case without 
much jaundice exploratory operation showed a very large red organ, with 
a slightly roughened surface. Microscopically the following characteris- 
tics are described by Trench writers: The cirrhosis is mono- or multilobular, 
with a connective tissue rich in round cells. The bile-vessels are the seat of 
an angiocholitis, catarrhal and productive, and there is an extraordinary 
development of new biliary canaliculi. The liver-cells are neither fatty 
nor pigmented, and may be increased in size and show karyokinetic figures. 
From the supposed origin about the bile-vessels it has been called biliary cir- 
rhosis, but the histological details have not yet been worked out fully, and 
the separation of this as a distinct form should, for the present at least, rest 



THE CIRRHOSES OF THE LIVER. 



575 



upon clinical rather than anatomical grounds. The spleen is greatly en- 
larged and may weigh 600 or more grammes. 

Symptoms. — Hanot's hypertrophic cirrhosis presents the following 
very characteristic group of symptoms. As previously stated, the cases 
occur in young persons; there is not, as a rule, an alcoholic history, and 
males are usually affected: (a) A remarkably chronic course of from four 
to six, or even ten years, (b) Jaundice, usually slight, often not more than 
a lemon tint, or a tinging of the conjunctivas. At any time during the 
course an icterus gravis, with high fever and delirium, may develop. There 
is bile in the urine; the stools are not clay-colored as in obstructive jaundice, 
but may be very dark and " bilious." (c) Attacks of pain in the region of the 
liver, which may be severe and associated with nausea and vomiting. The 
pain may be slight and dragging, and in some cases is not at all a prom- 
inent symptom. The jaundice may deepen after attacks of pain, (d) 
Enlarged liver. A fulness in the upper abdominal zone may be the first 
complaint. On inspection the enlargement may be very marked. In one 
of my cases the left lobe was unusually prominent and stood out almost 
like a tumor. An exploratory operation showed only an enlarged, smooth 
organ without adhesions. On palpation the hypertrophy is uniform, the 
consistence is increased, and the edge distinct and hard. The gall-bladder 
is not enlarged. The vertical flatness is much increased and may extend 
from the sixth rib to the level of the navel, (e) The spleen is enlarged, eas- 
ily palpable, and very hard. (/) Certain negative features are of moment — 
absence of ascites and of dilatation of the subcutaneous veins of the abdo- 
men. Among other symptoms may be mentioned haemorrhages. One of 
my cases had bleeding at the gums for a year; another had had for years 
most remarkable attacks of purpura with urticaria. Pruritus, xanthoma, 
lichen, and telangiectasies may be present in the skin. In one of my cases 
the skin became very bronzed, almost as deeply as in Addison's disease. 
Slight fever may be present, which increases during the crises of pain. 
There may be a marked leucocytosis. A curious attitude of the body has 
been seen, in which the right shoulder and right side look dragged down. 
The patients die with the symptoms of icterus gravis, from haemorrhage, 
from an intercurrent infection, or in a profound cachexia. Certain of the 
cases of cirrhosis of the liver in children are of this type; the enlargement 
of the spleen may be very pronounced. 

III. SYPHILITIC CIRRHOSIS. 

This has already been considered in the section on syphilis (p. 249). I 
refer to it again to emphasize (1) its frequency; (2) the great importance of 
its differentiation from the alcoholic form: (3) its curability in many cases; 
and (4) the tumor formations in connection with it. 

TV. CAPSULAR CIRRHOSIS— PERIHEPATITIS. 

Local capsulitis is common in many conditions of the liver. The form 
of disease here described is characterized by an enormous thickening of the 
entire capsule, with great contraction of the liver, but not necessarily with 
3G 



576 



DISEASES OF THE DIGESTIVE SYSTEM. 



special increase in the connective tissue of the organ itself. Our chief 
knowledge of the disease we owe to the Guy's Hospital physicians, particu- 
larly to Hilton Fagge and to Hale White, who has collected from the rec- 
ords 22 cases. The liver substance itself was " never markedly cirrhotic: 
its tissue was nearly always soft." Chronic capsulitis of the spleen and a 
chronic proliferative peritonitis are almost invariably present. In 19 of 
the 22 cases the kidneys were granular. Hale White regards it as a sequel 
of interstitial nephritis. The youngest case in his series was twenty-nine. 
The symptoms are those of atrophic cirrhosis — ascites, often recurring and 
requiring many tappings. J aundice is not often present. I have met with 
two groups of cases — the one in adults usually with ascites and regarded 
as ordinary cirrhosis. I have never made a diagnosis in such a case. Signs 
of interstitial nephritis, recurring ascites, and absence of jaundice are re- 
garded by Hale White as important diagnostic points. In the second 
group of cases the perihepatitis, perisplenitis, and proliferative peritonitis 
are associated with adherent pericardium and chronic mediastinitis. In one 
such case the diagnosis of capsular hepatitis was very clear, as the liver 
could be grasped in the hand and formed a rounded, smooth organ resem- 
bling the spleen. The child was tapped 121 times (Archives of Paediatrics, 
1896). 

Treatment of the Cirrhoses. — Ordinary cirrhosis of the liver is 
an incurable disease. Many writers, speaking of the curability of certain 
forms, show a lack of appreciation of the essential conditions upon which 
the symptoms depend. So far as we have any knowledge, no remedies at 
our disposal can alter or remove the cicatricial connective tissue which con- 
stitutes the materia peccans in ordinary cirrhosis. On the other hand, we 
know that extreme grades of contraction of the liver may persist for years 
without symptoms when the compensatory circulation exists. The so-called 
cure of cirrhosis means the re-establishment of this compensation; and it 
would be as unreasonable to speak of healing a chronic valvular lesion when 
with digitalis we have restored the circulatory balance as it is to speak of 
curing cirrhosis of the liver, when by tapping and other measures the com- 
pensation has'in some way been restored. 

The patient should abstain entirely from alcohol, and, if possible, should 
take a milk diet, which has been highly recommended by Semmola. In 
any case, the diet should be nutritious, but not too rich. Measures should 
be employed to reduce the gastro-intestinal catarrh, and the patient should 
lead a quiet, out-of-door life and keep the skin active, the bowels regular, 
and the urine abundant. In non-syphilitic cases it is useless to give either 
mercury or iodide of potassium. When a well-marked history of syphilis 
exists these remedies should be used, but neither of them has any more 
influence upon the development of a new growth of connective tissue in 
the liver than it has upon the progressive development of a scar tissue in 
a keloid or in an ordinary developing cicatrix. The ascites should be 
tapped early, and the operation may be repeated so soon as the distention 
becomes distressing. The continuous drainage with a Southey's tube may 
be employed. It is much better to resort to tapping early if after a few 
days' trial the fluid does not subside rapidly under the use of saline purges. 



ABSCESS OF THE LIVER. 



577 



Trom half an ounce to an ounce and a half of magnesium sulphate may 
be given in as little water as possible half an hour before breakfast. Elate- 
rium, the compound jalap powder, or the bitartrate of potash may also be 
employed. Digitalis and squills are often useful. Surgical treatment has 
been advocated of late. The abdomen is thoroughly drained and the surface 
of the liver and spleen and the parietal peritonaaum is then firmly scrubbed, 
so as to promote adhesions, in which compensatory vessels could develop. 
Of three cases recently treated in my wards in this way one has recovered. 
In the syphilitic cases, or when syphilis is suspected, iodide of potassium may 
be given in doses of from 15 to 30 drops of the saturated solution three 
times a day, and mercury, which is conveniently given with squills and 
digitalis in the form of Addison's or Memeyer's pill. A patient with well- 
marked syphilitic cirrhosis with recurring ascites, in which tapping was re- 
sorted to on eight or ten occasions, took this pill at intervals for a year with 
the greatest benefit and subsequently had four years of tolerably good 
health. 

VIII. ABSCESS OF THE LIVER. 

Etiology. — Suppuration within the liver, either in the parenchyma or 
in the blood or bile passages, occurs under the following conditions: 

(1) The tropical abscess. In hot climates this form may develop idio- 
pathically, but more commonly follows dysentery. It frequently occurs 
among Europeans in India, particularly those who drink alcohol freely and 
are exposed to great heat. The relation of this form of abscess to dysen- 
tery is still under discussion, and Anglo-Indian practitioners are by no 
means unanimous on the subject. Certainly cases may develop without 
a history of previous dysentery, and there have been fatal cases without 
any affection of the large bowel. In this country the large solitary tropical 
abscess also occurs, oftenest in the Southern States. In Baltimore it is not 
very infrequent. 

The relation of this form of abscess to the amceba coli has been care- 
fully studied by Kartulis and exhaustively considered in a monograph by 
Councilman and Lafleur. The descriptions and illustrations of these au- 
thors are most convincing as to the direct etiological association of this 
organism with liver abscess. Clinically the patient may have amoeba coli 
in the stools and well-marked signs of liver abscess without marked symp- 
toms of dysentery and even with the fasces well formed. 

(2) Traumatism is an occasional cause. The injury is generally in the 
hepatic region. Two instances have come under my notice of it in brake- 
men who were injured while coupling cars. Injury to the head is not in- 
frequently followed by liver abscess. 

(3) Embolic or pysemic abscesses are the most numerous, and may de- 
velop in a .L r <'ncnil pyaemia from any cause or follow foci of suppuration in 
the territory of the portal vessels. The infective agents may reach the 
liver through the hepatic artery, as in those cases in which the original 
focus of infection is in the area of the systemic circulation; though it may 
happen occasionally that the infective agent, instead of passing through 



578 



DISEASES OF THE DIGESTIVE SYSTEM. 



the lungs, reaches the liver through the inferior vena cava and the hepatic 
veins. A remarkable instance of multiple abscesses of arterial origin was 
afforded by the case of aneurism of the hepatic artery reported by Ross 
and myself. Infection through the portal vein is much more common. It 
results from dysentery and other ulcerative affections of the bowels, appen- 
dicitis, occasionally after typhoid fever, in rectal affections, and in abscesses 
in the pelvis. In these cases the abscesses are multiple and, as a rule, within 
the branches of the portal vein — suppurative pylephlebitis. 

(4) A not uncommon cause of suppuration is inflammation of the bile- 
passages caused by gall-stones, more rarely by parasites — suppurative cho- 
langitis. 

In some instances of tuberculosis of the liver the affection is chiefly of 
the bile-ducts, with the formation of multiple tuberculous abscesses con- 
taining a bile-stained pus. 

(5) Foreign bodies and parasites. In rare instances foreign bodies, such 
as a needle, may pass from the stomach or gullet, lodge in the liver, and 
excite an abscess, or, as in several instances which have been reported, a 
foreign body, such as a needle or a fish-bone, has perforated a branch or 
the portal vein itself and induced extensive pylephlebitis. Echinococcus 
cysts frequently cause suppuration; the penetration of round worms into 
the liver less commonly; and most rarely of all the liver-fluke. 

Morbid Anatomy. — (a) Of the Solitary or Tropical Abscess. — This 
is not always single; there may be two or even more large abscess cavities, 
ranging in size from an orange to a child's head. The largest-sized ab- 
scess may contain from 3 to 6 litres of pus and involve more than three 
fourths of the entire organ. In Waring's statistics, 62 per cent of the cases 
were single. The abscess in nearly 70 per cent of the cases was in the 
right lobe, more toward the convexity than the concave side. In long- 
standing cases the abscess-wall may be firm and thick, but, as a rule, the 
cavity possesses no definite limiting membrane, and section of the wall 
shows an internal layer grayish in color, shreddy, and made up of necrotic 
liver substance, pus-cells, and amoebae; a middle layer, brownish red in 
color; and an external zone of hypersemic liver tissue. The pus is often 
reddish brown in color, closely resembling anchovy sauce. In other in- 
stances it is grayish white, mucoid, and may be quite creamy. The odor 
is at times very peculiar. In one instance it had the sour smell of chyme, 
though no connection with the stomach was found. In amoebic dysen- 
tery there may also be multiple miliary abscesses in the liver, containing 
amoebae. 

The bacteriological examination of the contents show either a sterile pus 
or, in some cases, staphylococci, streptococci, or the colon bacillus. The 
termination of this form of abscess may be as follows, as noted in Waring's 
300 cases: Eemained intact, 56 per cent; opened by operation, 16 per cent; 
perforated the right pleura, nearly 5 per cent; ruptured into the right lung, 
9 per cent; ruptured into the peritonaeum, 5 per cent; ruptured into the 
colon, nearly 3 per cent; and there were, in addition, instances which rup- 
tured into the hepatic and bile-vessels and into the gall-bladder. Flexner 
has reported two cases of perforation into the inferior vena cava. For a full 



ABSCESS OF THE LIVER. 



579 



consideration of the subject of amoebic abscess of the liver the reader is 
referred to Lafleur's article in Allbutt's System of Medicine. 

(b) Of Septic and Pycemic Abscesses. — These are usually multiple, though 
occasionally, following injury, there may be a large solitary collection of pus. 

In suppurative pylephlebitis the liver is uniformly enlarged. The cap- 
sule may be smooth and the external surface of the organ of normal ap- 
pearance. In other instances, numerous yellowish-white points appear be- 
neath the capsule. On section there are isolated pockets of pus, either 
having a round outline or in some places distinctly dendritic, and from 
these the pus may be squeezed. They look like small, solitary abscesses, 
but, on probing, are found to communicate with the portal vein and to 
represent its branches, distended and suppurating. The entire portal sys- 
tem within the liver may be involved; sometimes territories are cut off by 
thrombi. The suppuration may extend into the main branch or even into 
the mesenteric and gastric veins. The pus may be fetid and is often bile- 
stained; it may, however, be thick, tenacious, and laudable. In suppura- 
tive cholangitis there is usually obstruction by gall-stones, the ducts are 
greatly distended, the gall-bladder enlarged and full of pus, and the branches 
within the liver are extremely distended, so that on section there is an ap- 
pearance not unlike that described in pylephlebitis. 

Suppuration about the echinococcus cysts may be very extensive, forming 
enormous abscesses, the characters of which are at once recognized by the 
remnants of the cysts. 

Symptoms. — (a) Of the Large Solitary Abscess. — In the tropics there 
are instances in which the abscess appears to be latent and to run a course 
without definite symptoms; death may occur suddenly from rupture. 

Fever, pain, enlargement of the liver, and the development of a septic 
condition are the important symptoms of hepatic abscess. The tempera- 
ture is elevated at the outset and is of an intermittent or septic type. It 
is irregular, and may remain normal or even subnormal for a few days; 
then the patient has a rigor and the temperature rises to 103° or higher. 
Owing to this intermittent character of the fever the cases are usually, in 
this latitude, mistaken for malaria. The fever may rise every afternoon 
without a rigor. Profuse sweating is common, particularly when the pa- 
tient falls asleep. In chronic cases there may be little or no fever. One 
of my patients, with a liver abscess which had perforated the lung, coughed 
up pus after his temperature had been normal for weeks. The pain is 
variable, and is usually referred to the back or shoulder; or there is a dull 
aching sensation in the right hypochondrium. When turned on the left 
side, the patient often complains of a heavy, dragging sensation, so that 
he usually prefers to lie" on the right side; at least, this has been the case 
in a majority of the instances which have come under my observation. Pain 
on pressure over the liver is usually present, particularly on deep pressure 
at the costal margin in the nipple line. 

The enlargement of the liver is most marked in the right lobe, and, as 
the abscess cavity is usually situated more toward the upper than the un- 
der surface, the increase in volume is upward and to the right, not down- 
ward, as in cancer and the other affections producing enlargement. Per- 



580 



DISEASES OF THE DIGESTIVE SYSTEM. 



cussion in the mid-sternal and parasternal lines may show a normal limit. 
At the nipple-line the curve of liver dulness begins to rise, and in the mid- 
axillary it may reach the fifth rib, while behind, near the spine, the area 
of dulness may be almost on a level with the angle of the scapula. Of 
course there are instances in which this characteristic feature is not present, 
as when the abscess occupies the left lobe. The enlargement of the liver 
may be so great as to cause bulging of the right side, and the edge may 
project a hand's-breadth or more below the costal margin. In such in- 
stances the surface is smooth. Palpation is painful, and there may be 
fremitus on deep inspiration. In some instances fluctuation may be de- 
tected. Adhesions may form to the abdominal wall and the abscess may 
point below the margin of the ribs, or even in the epigastric region. In 
many cases the appearance of the patient is suggestive. The skin has a 
sallow, slightly icteroid tint, the face is pale, the complexion muddy, the 
conjunctivas are infiltrated, and often slightly bile-tinged. There is in the 
fades and in the general appearance of the patient a strong suggestion of 
the existence of abscess. There is no internal affection associated with sup- 
puration which gives, I think, just the same hue as certain instances of 
abscess of the liver. Marked jaundice is rare. Diarrhoea may be present 
and may give an important clew to the nature of the case, particularly if 
amoebae are found in the stools. Constipation may occur. 

Remarkable and characteristic symptoms arise when the abscess invades 
the lung.' The extension may occur through the diaphragm, without actual 
rupture, and with the production of a purulent pleurisy and invasion of 
the lung. The patients gradually develop a severe cough, usually of an 
aggravated and convulsive character, there are signs of involvement at the 
base of the right lung, defective resonance, feeble tufcular breathing, and 
increase in the tactile fremitus; but the most characteristic feature is the 
presence of a reddish-brown expectoration of a brick-dust color, resembling 
anchovy sauce. This, which was noted originally by Budd, was present 
in our cases, and in addition Reese and Lafleur found the amoebce coli iden- 
tical with those which exist in the liver abscess and in the stools. They 
are present in variable numbers and display active amoeboid movements. 
The brownish tint of the expectoration is due to blood-pigment and blood- 
corpuscles, and there may be orange-red crystals or hsematoidin. 

The abscess may perforate externally, as mentioned already, or into the 
stomach or bowel; occasionally into the pericardium. The duration of this 
form is very variable. It may run its course and prove fatal in six or eight 
weeks or may persist for several years. 

The prognosis is serious, as the mortality is more than 50 per cent. 
The death-rate has been lowered of late years, owing to the greater fearless- 
ness with which surgeons now attack these cases. 

(b) Of the Pycemic Abscess and Suppurative Pylephlebitis. — Clinically 
these conditions cannot be separated. Occurring in a general pyaemia, no 
special features may be added to the case. When there is suppuration 
within the portal vein the liver is uniformly enlarged and tender, though 
pain may not be a marked feature. There is an irregular, septic fever, and 
the complexion is muddy, sometimes distinctly icteroid. The features are 



ABSCESS OF THE LIVER. 



581 



indeed those of pyaemia, plus a slight icteroid tinge, and an enlarged and 
painful liver. The latter features alone are peculiar. The sweats, chills, 
prostration, and fever have nothing distinctive. 

Diagnosis. — Abscess of the liver may be confounded with intermit- 
tent fever, a common mistake in malarial regions. Practically an intermit- 
tent fever which resists quinine is not malarial. Laveran's organisms are 
also absent from the blood. When the abscess bursts into the pleura a 
right-sided empyema is produced and perforation of the lung usually fol- 
lows. When the liver abscess has been latent and dysenteric symptoms have 
not been marked, the condition may be considered empyema or abscess of 
the lung. In such cases the anchovy-sauce-like color of the pus and the 
presence of the amoebae will enable one to make a definite diagnosis, as has 
been done in cases by Lafleur. Perforation externally is readily recognized, 
and yet in an abscess cavity in the epigastric region it may be difficult to say 
whether it has proceeded from the liver or is in the abdominal wall. When 
the abscess is large, and the adhesions are so firm that the liver does not de- 
scend during inspiration, the exploratory needle does not make an up-and- 
down movement during aspiration. In an instance of this kind which I 
saw with Hearn at the Philadelphia Hospital, all the features, local and 
general, seemed to point to abscess in the abdominal wall, but the operation 
revealed a large perforating abscess cavity in the left lobe of the liver. The 
diagnosis of suppurating echinococcus cyst is rarely possible, except in 
Australia and Iceland, where hydatids are so common. 

Perhaps the most important affection from which suppuration within 
the liver is to be separated is the intermittent hepatic fever associated with 
gall-stones. Of the cases reported a majority have been considered due to 
suppuration, and in two of my cases the liver had been repeatedly aspirated. 
Post-mortem examinations have shown conclusively that the high fever and 
chills may recur at intervals for years without suppuration in the ducts. 
The distinctive features of this condition are paroxysms of fever with 
rigors and sweats — which may occur with great regularity, but which more 
often are separated by long intervals — the deepening of the jaundice after 
the paroxysms, the entire apyrexia in the intervals, and the maintenance 
of the general nutrition. The time element also is important, as in some 
of these cases the disease has lasted for several years. Finally, it is to be 
remembered that abscess of the liver, in temperate climates at least, is in- 
variably secondary, and the primary source must be carefully sought for, 
either in dysentery, slight ulceration of the rectum, suppurating haemor- 
rhoids, ulcer of the stomach, or in suppurative diseases of other parts of the 
body, particularly in the skull or in the bones. 

The presence of a leucocytosis is a most important feature in all forms 
of suppuration of the liver. 

In suspected cases, whether the liver is enlarged or not, exploratory 
aspiration may be performed without risk. The needle may be entered in 
the anterior axillary line in the lowest interspace, or in the seventh inter- 
space in the mid-axillary line, or over the centre of the area of dulness 
behind. The patient should be placed under ether, for it may be neces- 
sary to make several deep punctures. It is not well to use too small an 



582 



DISEASES OF THE DIGESTIVE SYSTEM. 



aspirator. No ill effects follow this procedure, even though blood may 
leak into the peritoneal cavity. Extensive suppuration may exist, and yet 
be missed in the aspiration, particularly when the branches of the portal 
vein are distended with pus. 

Treatment.— P3 r aemic abscess and suppurative pylephlebitis are in- 
variably fatal. Treves, however, reports a case of pyasmic abscess following 
appendicitis in which the patient recovered after an exploratory operation. 
Surgical measures are not justified in these cases, unless an abscess shows 
signs of pointing. As the abscesses associated with dysentery are often single, 
they afford a reasonable hope of benefit from operation. If, however, the 
patient is expectorating the pus, if the general condition is good and the 
hectic fever not marked, it is best to defer operation, as many of these in- 
stances recover spontaneously. The large single abscesses are the most 
favorable for operation. The general medical treatment of the cases is that 
of ordinary septicaemia. 



IX. NEW GROWTHS IN THE LIVER. 

These may be cancer, either primary or secondary, sarcoma, or angioma. 

Etiology. — Cancer of the liver is third in order of frequency of in- 
ternal cancer. It is rarely primary, usually secondary to cancer in other 
organs. It is a disease of late adult life. According to Leichtenstern, 
over 50 per cent of the cases occur between the fortieth and the sixtieth 
years. It occasionally occurs in children. Women are attacked less 
frequently than men. It is stated by some authors that secondary can- 
cer is more common in women, owing to the frequency of cancer of the 
uterus. Heredity is believed to have an influence in from 15 to 20 per 
cent. 

In many cases trauma is an antecedent, and cancer of the bile-passages 
is associated in many instances with gall-stones. Cancer is stated to be less 
common in the tropics. Its relative proportion to other diseases may be 
judged from the fact that among the first 3,000 patients admitted to the 
wards of the Johns Hopkins Hospital there were seven cases of cancer of 
the liver. 

Morbid Anatomy. — The following forms of new growths occur in 
the liver and have a clinical importance: 

Cancer. — (1) Primary cancer, of which three forms may be recognized.* 

(a) The massive cancer, which causes great enlargement and on section 
shows a uniform mass of new growth, which occupies a large portion of 
the organ. It is grayish white, usually not softened, and is abruptly out- 
lined from the contiguous liver substance. 

(b) Nodular cancer, in which the liver is occupied by nodular masses, 
some large, some small, irregularly scattered throughout the organ. Usu- 
ally in one region there is a larger, perhaps firmer, older-looking mass, which 
indicates the primary seat, and the numerous nodules are secondary to it. 



* Hanot and Gilbert, Etudes sur les Maladies du Foie, Paris, 1888. 



NEW GROWTHS IN THE LIVER. 



583 



This form is much like the secondary cancerous involvement, except that 
it seldom reaches a large size. 

(c) The third is the remarkable and rare variety, cancer with cirrhosis, 
which forms an anatomical picture perfectly unique and at first very puz- 
zling. The liver is not much enlarged, rarely weighing more than 2-J or 
3 kilogrammes. The surface is grayish yellow, studded over with nodular 
yellowish masses, resembling the projections in an ordinary cirrhotic liver. 
On section the cancerous nodules are seen scattered throughout the entire 
organ, varying in diameter from 3 to 10 or more millimetres and sur- 
rounded with fibrous tissue. 

Histologically, the primary cancers are epitheliomata — alveolar and 
trabecular. The character of the cells varies greatly. In some varieties they 
are polymorphous; in others small polyhedral; in others, again, giant cells 
are found. In rare instances, as in one described by Greenfield, the cells are 
cylindrical. The trabecular form of epithelioma is also known as adenoma 
or adeno-carcinoma. 

(2) Secondary Cancer. — The organ is usually enormously enlarged, and 
may weigh 20 pounds or more. The cancerous nodules project beneath 
the capsule, and can be felt during life or even seen through the thin ab- 
dominal walls. They are usually disseminated equally, though in rare in- 
stances they may be confined to one lobe. The consistence of the nodules 
varies; in some cases they are firm and hard and those on the surface show 
a distinct umbilication, due to the shrinking of the fibrous tissue in the 
centre. These superficial cancerous masses are still sometimes spoken of 
as " Farre's tubercles." More frequently the masses are on section grayish 
white in color, or haemorrhagic. Eupture of blood-vessels is not uncommon 
in these cases. In one specimen there was an enormous clot beneath the 
capsule of the liver, together with haemorrhage into the gall-bladder and 
into the peritonaeum. The secondary cancer shows the same structure as 
the initial lesion, and is usually either an alveolar or cylindrical carcinoma. 
Degeneration is common in these secondary growths; thus the hyaline 
transformation may convert large areas into a dense, dry, grayish-yellow 
mass. Extensive areas of fatty degeneration may occur, sclerosis is not 
uncommon, and haemorrhages are frequent. Suppuration sometimes 
follows. 

(3) Cancer of the bile-passages which has been already considered. 
Sarcoma. — Of primary sarcoma of the liver very few cases have been 

reported. Secondary sarcoma is more frequent, and many examples of 
lymphosarcoma and myxo-sarcoma are on record, less frequently glio-sar- 
coma or the smooth or striped myoma. 

The most important form is the melano-sarcoma, which develops in the 
liver secondarily to sarcoma of the eye or of the skin. Very rarely melano- 
sarcoma develops primarily in the liver. Of the reported cases Hanoi ex- 
cludes all but one. In this form the liver is greatly enlarged, is either uni- 
formly infiltrated with the cancer, which gives the cut surface the appear- 
ance of dark granite, or there are large nodular masses of a deep black or 
marbled color. There are usually extensive metastases, and in some in- 
stances every organ of the body is involved. Nodules of melano-sarcoma 



584 



DISEASES OF THE DIGESTIVE SYSTEM. 



of the skin may give a clew to the diagnosis. Hamburger (J, H. H. Bulle- 
tin, 1898) has reported the cases which have been in my wards. 

Other Forms of Liver Tumor. — One of the commonest tnmors in the 
liver is the angioma, which occurs as a small, reddish body the size of a 
walnut, and consists simply of a series of dilated vessels. Occasionally in 
children angiomata have developed and produced large tumors. 

Cysts are occasionally found in the liver, either single, which are not 
very uncommon, or multiple, when they usually coexist with congenital 
cystic kidneys. 

Symptoms. — It is often impossible to differentiate primary and sec- 
ondary cancer of the liver unless the primary seat of the disease is evident, 
as in the case of scirrhus of the breast, or cancer of the rectum, or of a 
tumor in the stomach, which can be felt. As a rule, cancer of the liver is 
associated with progressive enlargement; but there are cases of primary 
nodular cancer, and in the cancer with cirrhosis the organ may not be en- 
larged. Gastric disturbance, loss of appetite, nausea, and vomiting are fre- 
quent. Progressive loss of flesh and strength may be the first symptoms. 
Pain or a sensation of uneasiness in the right hypochondriac region may 
be present, but enormous enlargement of the liver may occur without the 
slightest pain. Jaundice, which is present in at least one half of the cases, 
is usually of moderate extent, unless the common duct is occluded. As- 
cites is rare, except in the form of cancer with cirrhosis, in which the clinical 
picture is that of the atrophic form. Pressure by nodules on the portal 
vein or extension of the cancer to the peritonaeum may also induce ascites. 

Inspection shows the abdomen to be distended, particularly in the upper 
zone. In late stages of the disease, when emaciation is marked, the can- 
cerous nodules can be plainly seen beneath the skin, and in rare instances 
even the umbilications. The superficial veins are enlarged. On palpation 
the liver is felt, a handVbreadth or more below the costal margin, de- 
scending with each inspiration. The surface is usually irregular, and may 
present large masses or smaller nodular bodies, either rounded or with cen- 
tral depressions. In instances of diffuse infiltration the liver may be greatly 
enlarged and present a perfectly smooth surface. The growth is progres- 
sive, and the edge of the liver may ultimately extend below the level of the 
navel. Although generally uniform and producing enlargement of the 
whole organ, occasionally, when the tumor develops from the left lobe, it 
may form a solid mass, which occupies the epigastric region. By percussion 
the outline can be accurately limited and the progressive growth of the 
tumor estimated. The spleen is rarely enlarged. Pyrexia is present in many 
cases, usually a continuous fever, ranging from 100° to 102°; it may be in- 
termittent, with rigors. This may be associated with the cancer alone, or, 
as in one of my cases, with suppuration. (Edema of the feet, from anaemia, 
usually supervenes. Cancer of the liver kills in from three to fifteen months. 
One patient lived for more than two years. 

Diagnosis. — The diagnosis is easy when the liver is greatly enlarged 
and the surface nodular. The smoother forms of diffuse carcinoma may 
at first be mistaken for fatty or amyloid liver, but the presence of jaun- 
dice, the rapid enlargement, and the more marked cachexia will usually 



FATTY LIVER. 



585 



suffice to differentiate it. Perhaps the most puzzling conditions occur in 
the rare cases of enlarged amyloid liver with irregular gummata. The 
large echinococcus liver may present a striking similarity to carcinoma, but 
the projecting nodules are usually softer, the disease lasts much longer, and 
the cachexia is not marked. 

Hypertrophic cirrhosis may at first be mistaken for carcinoma, as the 
jaundice is usually deep and the liver very large; but the absence of a 
marked cachexia and wasting, and the painless, smooth character of the 
enlargement are points against cancer. When in doubt in these cases, 
aspiration may be safely performed, and positive indication may be gained 
from the materials so obtained. In large, rapidly growing secondary can- 
cers the superficial rounded masses may almost fluctuate and these soft 
tumor-like projections may contain blood. The form of cancer with cir- 
rhosis can scarcely be separated from atrophic cirrhosis itself. Perhaps 
the wasting is more extreme and more rapid, but the jaundice and the 
ascites are identical. Melano-sarcoma causes great enlargement of the 
organ. There are frequently symptoms of involvement of other viscera, 
as the lungs, kidneys, or spleen. Secondary tumors may develop on the" 
skin. A very important symptom, not present in all cases, is melanuria, 
the passage of a very dark-colored nrine, which may, however, when first 
voided, be quite normal in color. The existence of a melano-sarcoma of 
the eye, or the history of blindness in one eye, with subsequent extirpa- 
tion, may indicate at once the true nature of the hepatic enlargement. 
The secondary tumors may develop some time after the extirpation of 
the eye, as in a case under the care of J. C. Wilson, at the Philadelphia 
Hospital, or, as in a case under Tyson at the same institution, the pa- 
tient may have a sarcoma of the choroid which had never caused any symp- 
toms. 

The treatment must be entirely symptomatic. The question of surgical 
interference may be discussed. Keen has collected reports of 76 cases of 
resection of tumors of the liver, 63 of which recovered. 

X. FATTY LIVER. 

Two different forms of this condition are recognized — the fatty infil- 
tration and fatty degeneration. 

Fatty infiltration occurs, to a certain extent, in normal livers, since 
the cells always contain minute globules of oil. 

In fatty degeneration, which is a much less common condition, the 
protoplasm of the liver-cells is destroyed and the fat takes its place, as seen 
in cases of malignant jaundice and in phosphorus poisoning. 

Fatty liver occurs under the following conditions: (a) In association 
with general obesity, in which case the liver appears to be one of the store- 
houses of the excessive fat. (b) In conditions in which the oxidation pro- 
ei sses are interfered with, as in cachexia, profound ansemia, and in phthisis. 
The fatty infiltration of the liver in heavy drinkers is to be attributed to 
the excessive demand made by the alcohol upon the oxygen, (c) Certain 
poisons, of which phosphorus is the most characteristic, produce an intense 



586 



DISEASES OF THE DIGESTIVE SYSTEM. 



fatty degeneration with necrosis of the liver-cells. The poison of acute 
yellow atrophy, whatever its nature, acts in the same way. 

The fatty liver is uniformly increased in size. The edge may reach 
below the level of the navel. It is smooth, looks pale and bloodless; on 
section it is dry, and renders the surface of the knife greasy. The liver 
may weigh many pounds, and yet the specific gravity is so low that the 
entire organ floats in water. 

The symptoms of fatty liver are not definite. Jaundice is never pres- 
ent; the stools may be light-colored, but even in the most advanced grades 
the bile is still formed. Signs of portal obstruction are rare. Haemor- 
rhoids are not very infrequent. Altogether, the symptoms are ill-defined, 
and chiefly those of the disease with which the degeneration is associated. 
In cases of great obesity, the physical examination is uncertain; but in 
phthisis and cachectic conditions, the organ can be felt to be greatly en- 
larged, though smooth and painless. Fatty livers are among the largest 
met with at the bedside. 



XI. AMYLOID LIVER. 

The waxy, lardaceous, or amyloid liver occurs as part of a general de- 
generation, associated with cachexias, particularly when the result of long- 
standing suppuration. 

In practice, it is found oftenest in the prolonged suppuration of tuber- 
culous disease, either of the lungs or of the bones. Next in order of fre- 
quency are the cases associated with syphilis. Here there may be ulcera- 
tion of the rectum, with which it is often connected, or chronic disease of 
the bone, or it may be present when there are no suppurative changes. It 
is found occasionally in rickets, in prolonged convalescence from the infec- 
tious fevers, and in the cachexia of cancer. 

The amyloid liver is large, and may attain dimensions equalled only 
by those of the cancerous organ. Wilks speaks of a liver weighing four- 
teen pounds. It is solid, firm, resistant, on section ansemic, and has a 
semitranslucent, infiltrated appearance. Stained with a dilute solution of 
iodine, the areas infiltrated with the amyloid matter assume a rich mahog- 
any-brown color. The precise nature of this change is still in question. 
It first attacks the capillaries, usually of the median zone of the lobules, 
and subsequently the interlobular vessels and the connective tissue. The 
cells are but little if at all affected. 

There are no characteristic symptoms of this condition. Jaundice 
does not occur; the stools may. be light-colored, but the secretion of bile 
persists. The physical examination shows the organ to be uniformly en- 
larged and painless, the surface smooth, the edges rounded, and the con- 
sistence greatly increased. Sometimes the edge, even in very great enlarge- 
ment, is sharp and hard. The spleen also may be involved, but there are 
no evidences of portal obstruction. 

The diagnosis of the condition is, as a rule, easy. Progressive and great 
enlargement in connection with suppuration of long standing or with 



ANOMALIES IN FORM AND POSITION OF THE LIVER. 



587 



syphilis, is almost always of this nature. In rare instances, however, the 
amyloid liver is reduced in size. 

In leukcemia the liver may attain considerable size and be smooth and 
uniform, resembling, on physical examination, the fatty organ, The blood 
condition at once indicates the true nature of the case. 



XII. ANOMALIES IN FORM AND POSITION OF THE 

LIVER. 

In transposition of the viscera the right lobe of the organ may occupy 
the left side. A common and important anomaly is the tilting forward of 
the organ, so that the long axis is vertical, not transverse. Instead of the 
edge of the right lobe presenting just below the costal margin, a consider- 
able portion of the surface of the lobe is in contact with the abdominal 
parietes, and the edge may be felt as low, perhaps, as the navel. This an- 
teversion is apt to be mistaken for enlargement of the organ. 

The " lacing " liver is met with in two chief types. In one, the anterior 
portion, chiefly of the right lobe, is greatly prolonged, and may reach the 
transverse navel line,, or even lower. A shallow transverse groove sepa- 
rates the thin extension from the main portion of the organ. The peri- 
toneal coating of this groove may be fibroid, and in rare instances the de- 
formed portion is connected with the organ by an almost tendinous mem- 
brane. The liver may be compressed laterally and have a pyramidal shape, 
and the extreme left border and the hinder margin of the left lobe may be 
much folded and incurved. The projecting portion of the liver, extending 
low in the right flank, may be mistaken for a tumor, or more frequently 
for a movable right kidney. Its continuity with the liver itself may not 
be evident on palpation or on percussion, as coils of intestine may lie in 
front. It descends, however, with inspiration, and usually the margin 
can be traced continuously with that of the left lobe of the liver. The 
greatest difficulty arises when this anomalous lappet of the liver is either 
naturally very thick and united to the liver by a very thin membrane, or 
when it is swollen in conditions of great congestion of the organ. 

The other principal type of lacing liver is quite different in shape. It 
is thick, broader above than below, and lies almost entirely above the trans- 
verse line of the cartilages. There is a narrow groove just above the anterior 
border, which is placed more transversely than normal.* 

Movable Liver. — This rare condition has received much attention of 
late, and J. E. Graham, in a recent paper, has collected 70 reported cases 
from the literature. In a very considerable number of these there has been 
a mistakeD diagnosis. A slight grade of mobility of the organ is found 
in the pendulous abdomen of enteroptosis, and after repeated ascites. 

The organ is so connected at its posterior margin with the inferior 
vena cava and diaphragm that any great mobility from this point is im- 



* Sec P. Hertz, Abnormitiiten in der Lage und Form der Bauchorgane, Berlin, 1894. 



5S8 



DISEASES OF THE DIGESTIVE SYSTEM. 



possible, except on the theory of a meso-hepar or congenital ligamentous 
union between these structures. The ligaments, however, may show an 
extreme grade of relaxation (the suspensory 7.5 cm., and the triangular 
ligament 4 cm., in one of Leube's cases); and when the patient is in the 
erect posture the organ may drop down so far that its upper surface is 
entirely below the costal margin. The condition is rarely met with in men; 
56 of the cases were in women. 



IX. DISEASES OF THE PANCREAS. 

The importance of diseases of the pancreas has been emphasized, par- 
ticularly through studies made in this country by F. W. Draper on haemor- 
rhage and by Fitz on acute pancreatitis, while those of Senn have created 
a surgery of the gland. An additional interest has been given to the organ 
by the" work of v. Mering and Minkowski on pancreatic diabetes. The works 
of Claessen (1842) and of Ancelet (1866) give the older literature. The 
modern study of the subject dates from Sennas paper in the American 
Journal of the Medical Sciences, 1885, and Fitz's Middleton Goldsmith 
Lecture for 1889. In rewriting this section I have drawn freely on 
Ivorte's recent monograph. 



I. HEMORRHAGE. 

Both Spiess (1866) and Zenker (1874) were acquainted with haemor- 
rhage into the pancreas as a cause of sudden death, but the great medico- 
legal importance of the subject was first fully recognized by F. W. Draper, 
of Boston, whose townsmen, Harris, Fitz, Whitney, and others have con- 
tributed additional studies. In 4,000 autopsies Draper met with 19 cases 
of pancreatic haemorrhage, in 9 or 10 of which no other cause of death was 
found. When the bleeding is extensive the entire tissue of the gland is 
destroyed and the blood invades the retro-peritoneal tissue. In other in- 
stances the peritoneal covering is broken and the blood fills the lesser peri- 
tonaeum (see haemo-peritonaeum). The haemorrhage may be in connection 
with an acute pancreatitis or with necrotic inflammation of the gland. In 
an instance in which there was a small growth in the tail of the pancreas I 
found haemorrhage into the gland and into the retro-peritonaeum, forming 
a blood sac which surrounded the left kidney. 

Zenker suggests that the sudden death in these cases is due to shock 
through the solar plexus. 

The symptoms are thus briefly summarized by Prince: " The patient, 
who has previously been perfectly well, is suddenly taken with the illness 
which terminates his life. . . . When the haemorrhage occurs the patient 
may be quietly resting or pursuing his usual occupation. The pain which 
ushers in the attack is usually very severe and located in the upper part of 
the abdomen. It steadily increases in severity, is sharp or perhaps colicky 



ACUTE PANCREATITIS. 



589 



in character. It is almost from the first accompanied by nausea and vom- 
iting; the latter becomes frequent and obstinate, but gives no relief. The 
patient soon becomes anxious, restless, and depressed; he tosses about, and 
only with difficulty can he be restrained in bed. The surface is cold and 
the forehead is covered with a cold sweat. The pulse is weak, rapid, and 
sooner or later imperceptible. The abdomen becomes tender, the tender- 
ness being located in the upper part of the abdomen or epigastrium. Tym- 
panites is sometimes marked. The temperature in most cases is either 
normal or below normal. The bowels are apt to be constipated. These 
symptoms continue without relief, those which are most striking being 
the pain, vomiting, anxiousness, restlessness, and the state of collapse into 
which the patient soon falls." 

It has been suggested in such cases to open the abdomen, expose the 
pancreas, and relieve the tension, since the fatal result is often due to the 
pressure and not to the loss of blood. 



II. ACUTE PANCREATITIS. 

(a) Acute Hemorrhagic Pancreatitis. — In this form the inflammation 
is combined with haemorrhage, and it is difficult to separate clearly the two 
processes. 

Etiology. — Korte has collected 41 instances, of which only 4 were in 
women. A large majority of the cases occur in adult males. McPhedran 
has reported one in a nine months' old child. Many of the patients had 
been addicted to alcohol; others had suffered occasionally with severe pains 
and vomiting or with gall-stone colic. 

The pancreas is found enlarged, and the interlobular tissue infiltrated 
with blood, and perhaps with clots. The relation of gall-stones to the 
condition has been demonstrated in a recent case (Opie). A small calculus 
had lodged in the diverticulum of Vater, closing its duodenal orifice and 
converting the common bile duct and the duct of Wirsung into a closed 
channel. Bile finding its way into the pancreas had caused hemorrhagic 
inflammation. Injection of bile into the pancreatic ducts of clogs repro- 
duces the lesion. The gland cells have undergone more or less widespread 
necrosis, and at the margin of the necrotic areas are accumulations of 
inflammatory products, red blood-corpuscles, polynuclear leucocytes, and 
fibrin. There can be seen about the lobules and upon the omentum and 
mesentery opaque white specks, the fat necroses of Baker. 

Symptoms. — One of the most characteristic features is the sudden- 
ness of the onset, usually with violent colicky pain in the upper part of the 
abdomen. Nausea and vomiting follow, with collapse symptoms, more or 
less severe according to the intensity of the attack. The abdomen becomes 
swollen and tense and there is constipation. The temperature al first may 
be low; subsequently fever sets in, sometimes initiated by a chill. There 
may be early delirium. Collapse symptoms supervene, and death occur* 
usually from the second to the fourth day, or even earlier. The swelling 
and infiltration in the region of the pancreas necessarily involve the eceliac 
plexus, and the stretching of the nerves may account for the agonizing pain 



590 



DISEASES OP THE DIGESTIVE SYSTEM. 



and the sudden collapse. In a case which I have reported the semilunar 
ganglia were swollen, the nerve-cells indistinct, and there was an intersti- 
tial infiltration of round cells. The Pacinian corpuscles in the neighbor- 
hood of the pancreas were enormously swollen and cedematous. 

Deep pressure on the upper part of the abdomen may give evidence of 
circumscribed resistance. 

Diagnosis. — Intestinal obstruction or acute perforating peritonitis 
is usually suspected. Now that the condition has become better known 
the diagnosis intra vitam has been made (by Fitz and by Thayer). " Acute 
pancreatitis is to be suspected when a previously healthy person or a suf- 
ferer from occasional attacks of indigestion is suddenly seized with a violent 
pain in the epigastrium followed by vomiting and collapse, and in the course 
of twenty-four hours by a circumscribed epigastric swelling, tympanitic 
or resistant, with slight elevation of temperature. Circumscribed tender- 
ness in the course of the pancreas and tender spots throughout the abdomen 
are valuable diagnostic signs " (Fitz). An interesting case admitted to the 
Johns Hopkins Hospital illustrates a common mistake. The young man 
had had symptoms of obstruction of the bowels for three or four days. The 
abdomen was distended, tender, and very painful. I saw him on admission, 
agreed in the diagnosis of probable obstruction, and ordered him to be 
transferred at once to the operating-room. Halsted found no evidence of 
obstruction, but in the region of the pancreas and at the root of the mesen- 
tery there was a dense, thick, indurated mass, and there were areas of fat- 
necrosis in both mesentery and omentum. Oddly enough this patient re- 
turned four years afterward with another attack, but he refused to be 
operated upon and was taken away by his friends. 

(h) Acute Suppurative Pancreatitis — Pancreatic Abscess— Fitz, in his 
monograph in 1889, reported 22 cases. To this list Korte has added 24. 
Of the cases, 32 were in males. 

The etiology in a majority of cases is doubtful. Dyspeptic disturbances 
and trauma have preceded the onset in some instances. In 24 cases there 
was a single abscess; in 14 there were numerous small abscesses. In other 
instances there was a diffuse purulent infiltration. Some of the sequels 
are peri-pancreatic abscess, perforation into the stomach, the duodenum, or 
the peritonaeum, and thrombosis of the portal vein. 

The symptoms of suppurative pancreatitis are not always well defined. 
In one case in my wards Thayer made a correct diagnosis. The patient, 
aged thirty-four, had had occasional attacks of severe pain and vomiting. 
This was followed by fever and delirium. A deep-seated mass was felt in 
the median line just above the umbilicus. Finney operated and found 
disseminated fat-necrosis and a deep-seated abscess with necrotic pancre- 
atic tissue. The patient recovered. The course of the suppurative form 
is much more chronic. Icterus, fatty diarrhoea, and sugar in the urine 
have been met with in some cases. The presence of a tumor mass in the 
epigastrium is of the greatest moment. 

(c) Gangrenous Pancreatitis. — Complete necrosis of the gland, or part 
of it, may follow either haemorrhage or hemorrhagic inflammation, and in 
exceptional eases may occur after suppurative infiltration or after injury 



ACUTE PANCREATITIS. 



591 



or the perforation of an ulcer of the stomach. In Fitz's monograph 15 
cases are reported. Korte has increased this number to 40. Symptoms of 
hemorrhagic pancreatitis may precede or be associated with it. Death 
usually follows in from ten to twenty days, with symptoms of collapse. 

Anatomically the pancreas may present a dry necrotic appearance, but 
as a rule the organ is converted into a dark slaty-colored mass lying nearly 
free in the omental cavity or attached by a few shreds. In other instances 
the totally or partially sequestrated organ may lie in a large abscess cavity, 
forming a palpable tumor in the epigastric region. In two cases, reported 
by Chiari, the necrotic pancreas was discharged per rectum, with recovery. 

Relation of Fat-necrosis to Pancreatic Disease.— In connection with all 
forms of pancreatic disease small yellowish areas, to which Balser first di- 
rected attention, may be found in the interlobular pancreatic tissue, in the 
mesentery, in the omentum, in the abdominal fatty, tissue generally, and 
occasionally in the pericardial and subcutaneous fat. It is stated that they 
may be present without disease of the gland, but this is doubtful. They 
are most frequent in the hemorrhagic and necrotic forms of pancreatitis, 
less common in the suppurative. In the pancreas the lobules are seen to be 
separated by a dead-white necrotic tissue, which gives a remarkable appear- 
ance to the section. In the abdominal fat the areas are usually not larger 
than a pin's head; they at once attract attention, and may be mistaken, on 
superficial examination, for miliary tubercles or neoplasms. They may be 
larger; instances have been reported in which they were the size of a hen's 
egg. On section they have a soft, tallowy consistence. E. Langerhans has 
shown that this substance is a combination of lime with certain fatty acids. 
They may be crusted with lime, and in a man, aged eighty, who died of 
Brighfs disease, I found the lobules of the pancreas entirely isolated by 
areas of fatty necrosis with extensive deposition of lime salts. There is no 
necessary etiological relation between disease of the pancreas and dissemi- 
nated fatty necroses of the abdomen at the time the latter are discovered. 
They have been found accidentally in laparotomy for ovarian tumor and in 
instances in which the pancreas has been normal. They may be present in 
thin persons or in association with gall-stones. The bacterium coli com- 
mune was present in two instances, with diphtheritic colitis, examined by 
Welch, though in most cases the areas of necrosis are sterile. Langerhans 
produced fat-necrosis by injecting extract of pancreas into the peri-renal 
fatty tissue of a dog; and Hildebrand and Dettmer have shown expert 
mentally that the fat-necroses are caused by certain constituents of the pan- 
creatic juice, but not by trypsin. Flexner has demonstrated by chemical 
tests the existence of the fat-splitting ferment in peritoneal fat-necroses in 
recenl human and experimental eases. The ferment (steapsin) disappears 
after five or six days in experimental necroses, and can not be demonstrated 
in the lime-incrusted human ones. H. U. Williams has produced similar 
lesions in the subcutaneous fat by inserting bits of sterile pancreas beneath 
the skin. By Ligating the pancreatic ducts of cats Opie produced at the 
end of several weeks necrosis of almost the entire abdominal fat, together 
with foci in the subcutaneous tissue and in the pericardium. Flexner 
has produced acute haemorrhagic pancreatitis by injecting artificial gastric 
?,1 



592 



DISEASES OF THE DIGESTIVE SYSTEM. 



juice into the duct of Wirsung. Opie has recently made the interesting 
observation that hemorrhagic pancreatitis and fat-necrosis may be pro- 
duced by injecting bile into the pancreatic duct of dogs, and has also shown 
that the penetration of bile into the pancreas may be the cause of these 
conditions in human cases. 

It is well for surgeons to remember that in two cases at least the most 
serious symptoms of acute pancreatic disease have been found in association 
with only widespread fat-necrosis of the gland. In a case reported by 
Stockton and Williams a man, on his return journey from Europe, was 
seized with vomiting and pain, without fever, but with a very small pulse. 
The patient died soon after his arrival in America. The post mortem 
showed a pancreas 18 cm. long, at first sight normal, but on section most 
extensive fatty infiltration with fat-necrosis were demonstrable. 

HI. CHRONIC PANCREATITIS. 

Sclerosis follows obstruction of the duct of Wirsung by pancreatic cal- 
culi, by gall-stones lodged near the orifice of the common duct, and by 
neoplasm. Opie has distinguished two histological types of chronic in- 
flammation: (a) interlobular, including that caused by occlusion of the 
duct, and (b) interacinar, a more diffuse process invading the islands of 
Langerhans which are spared by the interlobular form. These varieties 
have much correspondence to the atrophic and hypertrophic cirrhosis of 
the liver. As already mentioned, it is probable that there is a close rela- 
tionship between disease of the islands of Langerhans and diabetes. Occa- 
sionally the gland is larger than normal, and may form a tumor readily 
palpable in the upper part of the abdomen. In hemochromatosis there 
may be pigmentary changes in association with a similar condition in the 
liver and pigmentation of the skin. 

The interest in atrophy of the pancreas relates first to the association 
with it of diabetes, which has been already considered; and secondly to the 
possibility of a chronic interstitial pancreatitis, particularly at the head of 
the organ, blocking the terminal part of the common bile-duct. Eiedel 
refers to severe cases in which he found during operation for gall-stones 
the head of the pancreas enlarged and hard as stone, so that he dreaded the 
possibility of new growth; but two of his patients recovered and were well 
for years, and in the third the post mortem showed that the condition was 
one of chronic pancreatitis. Similar cases are described by Mayo-Eobson. 
In one of Korte's cases a small nodule of the gland involved in a chronic 
pancreatitis had pressed directly upon the ductus communis choledochus 
and caused the jaundice. 

IV. PANCREATIC CYSTS. 

Of 121 cases operated upon by surgeons 60 were in males and 56 in 
females; in 5 the sex was not given (Korte). Sixty-six of the cases oc- 
curred in the fourth decade. T. C. Eailton's case (which is not in Korte's 
series), an infant aged six months, and Shattuck's case in a child of thir- 



PANCREATIC CYSTS. 



593 



teen and a half months, are the youngest in the literature. According to 
the origin Korte recognizes three varieties. 

(1) Traumatic Cases. — In this list of 33 cases 30 were in men and only 
3 in women. Blows on the abdomen or constantly repeated pressure are the 
most common forms of trauma. One case followed severe massage. Usu- 
ally with the onset there are inflammatory symptoms, pain, and vomiting, 
sometimes suggestive of peritonitis. The contents of the cyst are usually 
bloody, though in 13 of the traumatic cases it was clear or yellowish. 

(2) Cysts following Inflammatory Conditions. — In 51 cases the trouble 
began gradually after attacks of dyspepsia with colic, simulating somewhat 
that of gall-stones. Occasionally the attack set in with very severe symp- 
toms, suggestive of obstruction of the bowel. In this group the tumor ap- 
peared in 19 cases soon after the onset of the pain; in others it was delayed 
for a period of from a few weeks to two or three years. MePhedran has re- 
ported a remarkable instance in which the tumor developed in the epigas- 
trium with signs of severe inflammation. It was opened and drained and 
believed to be a hydrops of the lesser peritoneal cavity. Three months 
later a second cyst developed, which appeared to spring directly from the 
pancreas. 

(3) Cysts without any Inflammatory or Traumatic Etiology — Of 33 

cases in this group 26 were in women. A remarkable feature is the pro- 
longed period of their existence — in one case for forty-seven years, in one 
for between sixteen and twenty years, in others for sixteen, nine, and eight 
years, in the majority for from two to four years. 

Anatomically Korte recognizes (1) retention cysts due to plugging of 
the main duct; (2) proliferation cysts of the pancreatic tissue — the c3^sto- 
adenoma; (3) retention cysts arising from the alveoli of the gland and of the 
smaller ducts, which become cut off and dilate in consequence of chronic 
interstitial pancreatitis; (4) pseudo-cysts following inflammatory or trau- 
matic affections of the pancreas, usually the result of injury, causing 
haemorrhage and hydrops of the lesser peritonaeum. 

Situation. — In its growth the cyst may (1) develop in the lesser peri- 
tonaeum, push the stomach upward, and reach the abdominal wall between 
the stomach and the transverse colon; (2) more rarely the cyst appears 
above the lesser curvature and pushes the stomach downward; in both of 
these cases the situation of the tumor is high in the abdomen, but in (3) 
it may develop between the leaves of the transverse mesocolon and lie 
below both the colon and the stomach. The relation of these two organs 
to the tumor is variable, but in the majority of cases the stomach lies 
above and the transverse colon below the cyst. Occasionally, too, as in T. 
C. Kailton's case, the cyst may develop from the tail of the pancreas and 
project far over in the left hypochondrium in the position of the spleen 
or of a renal tumor. 

General Symptoms. — Apart from the features of onset already re- 
ferred to, the patient may complain of no trouble whatever, particularly in 
the very chronic cases, unless the cyst readies a very large size. Painful 
colicky attacks, with nausea and vomiting and progressive enlargement of 
the abdomen, have frequently been noted. Fatty diarrhoea from disturb- 



594 



DISEASES OF THE DIGESTIVE SYSTEM. 



ance of the function of the pancreas is rare. Sugar in the urine has been 
present in a number of cases. Increased secretion of the saliva, the so-called 
pancreatic salivation, is also rare. Pressure of the cyst may sometimes 
cause jaundice, and in rare instances dyspnoea. Very marked loss of flesh 
has been present in a number of cases. A remarkable feature often noticed 
has been the transitory disappearance of the cyst. In one of Halsted's cases 
the girth of the abdomen decreased from 43 to 31 inches in ten days with 
profuse diarrhoea. Sometimes the disappearance has followed blows. 

Diagnosis. — The cyst occupies the upper abdomen, usually forming 
a semicircular bulging in the median line, rarely to either side. In 16 
cases Korte states that the chief projection was below the navel. In one case 
operated upon by Halsted the tumor occupied the greater part of the abdo- 
men. The cyst is immobile, respiration having little or no influence on 
it. As already mentioned, the stomach, as a rule, lies above it and the colon 
below. 

In a majority of the cases the fluid is of a reddish or dark-brown color, 
and contains blood or blood coloring matter, cell detritus, fat granules, 
and sometimes cholesterin. The consistence of the fluid is usually mucoid, 
rarely thin. The reaction is alkaline, the specific gravity from 1.010 to 
1.020. In 22 cases Korte states that the fluid was not haemorrhagic. 

The existence of ferments is important. In 54 cases they were present 
in the fluid or in the material from the fistula. In 20 cases only one ferment 
was present, in 20 cases two, and in 14 cases all three of the pancreatic fer- 
ments were found. As diastatic and fat emulsifying ferments occur widely 
in various exudates the most important and only positive signs in the diag- 
nosis of the pancreatic secretion is the digestion of fibrin and albumin. 

Results. — Korte states of 101 cases in which the cyst was opened and 
drained 4 deaths followed the operation directly; 1 resulted from infec- 
tion of the fistula. In 14 cases the cyst was extirpated; of these 12 re- 
covered. In cases of Bull and of Kronig diabetes followed the extirpation 
of cysts. 

V. TUMORS OF THE PANCREAS. 

Of new growths in the organ carcinoma is the most frequent. Sarcoma, 
adenoma, and lymphoma are rare. 

Frequency. — At the General Hospital in Vienna in 18,069 autopsies 
there were 22 cases of cancer of the pancreas (Biach). In 11,472 post- 
mortems at Milan, Segre found 132 tumors of the pancreas, 127 of which 
were carcinomata, 2 sarcomata, 2 cysts, and 1 syphiloma. In 6,000 autop- 
sies at Guy's Hospital there were only 20 cases of primary malignant dis- 
ease of the organ (Hale White). In the first 1,500 autopsies at the Johns 
Hopkins Hospital there were 6 cases of adeno-carcinoma, and 1 doubtful 
case in which the exact origin could not be stated. There were 8 cases 
of secondary malignant disease of the pancreas. The head of the gland 
is most commonly involved, but the disease may be limited to the body or 
to the tail. The majority of the patients are in the middle period of life. 

Symptoms. — The diagnosis is not often possible. The following are 
the most important and suggestive features: (a) Epigastric pains, often 



PANCREATIC CALCULI. 



595 



occurring in paroxysms, (b) Jaundice, due to pressure of the tumor in 
the head of the pancreas on the bile-duct. The jaundice is intense and 
permanent, and associated with dilatation of the gall-bladder, which may 
reach a very large size, (c) The presence of a tumor in the epigastrium. 
This is very variable. In 137 cases Da Costa found the tumor present 
in only 13. Palpation under anaesthesia with the stomach empty would 
probably give a very much larger percentage. As the tumor rests directly 
upon the aorta there is usually a marked degree of pulsation, sometimes 
with a bruit. There may be pressure on the portal vein, causing throm- 
bosis and its usual sequels, (d) Symptoms due to loss of function of the 
pancreas are less important. Fatty diarrhoea is not very often present. In 
consequence of the absence of bile the stools are usually very clay-colored 
and greasy. Diabetes also is not common, (e) A very rapid wasting and 
cachexia. Of other symptoms nausea and vomiting are common. In some 
instances the pylorus is compressed and there is great dilatation of the 
stomach. In a few cases there has been profuse salivation. 

The points of greatest importance in the diagnosis are the intense and 
permanent jaundice, with dilatation of the gall-bladder, rapid emaciation, 
and the presence of a tumor in the epigastric region. Of less importance 
are features pointing to disturbance of the function of the gland. 

Of other new growths sarcoma and lymphoma have been occasionally 
found. Miliary tubercle is not very uncommon in the gland. Syphilis 
may occur as rather a chronic interstitial inflammation, or in the form of 
gummous tumors. 

The outlook in tumors of the pancreas is, as a rule, hopeless. How- 
ever, of 10 cases operated upon of late years, 6 recovered (Korte). 



VI. PANCREATIC CALCULI. 

Pancreatic lithiasis is comparatively rare. In 1883 George W. John- 
ston collected 35 cases in tlje literature. In 1,500 autopsies at the Johns 
Hopkins Hospital there were 2 cases. 

The stones are usually numerous, either round in shape or rough, 
spinous and coral-like. The color is opaque white. They are composed 
chiefly of carbonate of lime. The effects of the stones are: (1) A chronic 
interstitial inflammation of the gland substance with dilatation of the duct; 
sometimes there is cystic dilatation of the gland; (2) acute inflammation 
with suppuration; (3) the irritation of the stones, as in the gall-bladder, 
may load to carcinoma. 

Symptoms. — Pepper in 1882 made a diagnosis of calculus of the pan- 
creas, of which, however, there was no confirmation either by the passage 
of the stone or by autopsy. Minnich has reported a case in which, after an 
attack of colic, calculi composed of calcic carbonate and phosphate were 
passed in tlio stools. Lichtheim, in a case with severe colic, diabetes, and 
fatty diarrhoea, made the diagnosis of pancreatic calculi, which was after- 
ward confirmed by autopsy. 



596 



DISEASES OF THE DIGESTIVE SYSTEM. 



X. DISEASES OF THE PEKITON^EUM. 
I. ACUTE GENERAL PERITONITIS. 

Definition. — Acute inflammation of the peritonaeum. 
Etiology. — The condition may be primary or secondary. 

(a) Primary, Idiopathic Peritonitis. — Considering how frequently the 
pleura and pericardium are primarily inflamed the rarity of idiopathic in- 
flammation of the peritonaeum is somewhat remarkable. It may follow 
cold or exposure and is then known as rheumatic peritonitis. No instance 
of the kind has come under my notice. In Bright's disease, gout, and 
arterio-sclerosis acute peritonitis may develop as a terminal event. Of 102 
cases of peritonitis which came to autopsy at the Johns Hopkins Hospital, 
12 were of this form. In these there was some pre-existing chronic disease 
(Flexner). 

(b) Secondary peritonitis is due to extension of inflammation from, or 
perforation of one of the organs covered by the peritonaeum. Peritonitis 
from extension may follow inflammation of the stomach or intestines, ex- 
tensive ulceration in these parts, cancer, acute suppurative inflammations 
of the spleen, liver, pancreas, retroperitoneal tissues, and the pelvic vis- 
cera. • • 

Perforative peritonitis is the most common, following external wounds, 
perforation of ulcer of the stomach or bowels, perforation of the gall- 
bladder, abscess of the liver, spleen, or kidneys. Two important causes are 
appendicitis and suppurating inflammation about the Fallopian tubes and 
ovaries. There are instances in which peritonitis has followed rupture of 
an apparently normal Graafian follicle. 

Of the above 102 cases, 56 originated in an extension from some dis- 
eased abdominal viscus. The remaining 34 followed surgical operations 
upon the peritonaeum or the contained organs. 

The peritonitis of septicaemia and pyaemia is almost invariably the re- 
sult of a local process. An exceedingly acute form of peritonitis may be 
caused by the development of tubercles on the membrane. 

Morbid Anatomy. — In recent cases, on opening the abdomen the 
intestinal coils are distended and glued together by lymph, and the peri- 
tonaeum presents a patchy, sometimes a uniform injection. The exuda- 
tion may be: (a) Fibrinous, with little or no fluid, except a few pockets 
of clear serum between the coils, (b) Sero-fibrinous. The coils are cov- 
ered with lymph, and there is in addition a large amount of a yellowish, 
sero-fibrinous fluid. In instances in which the stomach or intestine is 
perforated this may be mixed with food or faeces, (c) Purulent, in which 
the exudate is either thin and greenish yellow in color, or opaque white 
and creamy, (d) Putrid. Occasionally in puerperal and perforative peri- 
tonitis, particularly when the latter has been caused by cancer, the exudate 
is thin, grayish green in color, and has a gangrenous odor, (e) Haemor- 
rhagic. This is sometimes found as an admixture in cases of acute peri- 
tonitis following wounds, and occurs in the cancerous and tuberculous 



ACUTE GENERAL PERITONITIS. 



597 



forms. (/) A rare form occurs in which the injection is present, but almost 
-all signs of exudation are wanting. Close inspection may be necessary to 
detect a slight dulling of the serous surfaces. The bacteriological exami- 
nation reveals large numbers of bacteria. 

The amount of the effusion varies from half a litre to 20 or 30 litres. 
There are probably essential differences between the various kinds of peri- 
tonitis. 

Bacteriology of Acute Peritonitis. — Much work has been done lately 
upon the subject. Flexner has analyzed 102 cases of peritonitis, in which 
bacteriological studies were made, which came to autopsy in the Johns 
Hopkins Hospital. He makes three classes. The first class embraces the 
primary or idiopathic form, of which 12 cases were found. These were 
with one exception mono-infections. The prevailing micro-organism was 
the streptococcus pyogenes (five times), the remaining ones being the staphy- 
lococcus aureus, micrococcus lanceolatus, bacillus proteus, pyocyaneus, and 
coli communis. The second class followed operations upon the peritonaeum, 
•excepting operations upon the intestine. The majority of these cases were 
examples of wound infection. They were 33 in number. In 25 of these 
mono-infections, in 8 mixed infections existed. The prevailing micro- 
organism was the staphylococcus aureus, which was present alone in 12 
and combined in 2 cases. The streptococcus occurred 5 times uncom- 
bined and -1 times combined. The bacillus coli was found 5 times in all, 
being unassociated in 3 cases. Other organisms found were the micro- 
coccus lanceolatus, staphylococcus albus, bacillus pyocyaneus, and serogenes 
capsulatus. The remaining 56 cases, forming the third class, were instances 
of intestinal infection. These comprised 23 mono- and 33 polyinfections. 
The predominating micro-organism was the bacillus coli communis which 
•occurred in 43 cases, 8 times alone and 35 in association. The strepto- 
•coccus was present in 37 cases, being alone in 7. The staphylococci, pneu- 
mococcus, bacillus proteus, pyocyaneus, typhosus, and aerogenes capsulatus 
occurred in a smaller number of instances. 

Among the micro-organisms thus far found rarely in peritonitis, may 
be mentioned the gonococcus, the anthrax bacillus, the proteus bacillus, 
and the typhoid bacillus. As illustrating the importance of the gonococ- 
cus, I may state that as I write there are two young girls both of whom 
were admitted to my wards with diffuse peritonitis arising from fresh 
gonorrhoea] salpingitis. Both were operated upon by Gushing success- 
fully. Welch has found the bacillus coli communis in peritonitis due to 
ulceration of the intestines without perforation. 

Symptoms. — In the perforative and septic cases the onset is marked 
by < l)illy feelings or an actual rigor with intense pain in the abdomen. In 
typhoid fever, when the sensorium is benumbed, the onset may not be 
noticed. The pain is general, and is usually intense and aggravated by 
movements and pressure. A position is taken which relieves the tension 
of the abdominal muscles, so that the patient lies on the back with the 
thighs drawn up and the shoulders elevated. The greatest pain is usually 
below the umbilicus, but in peritonitis from perforation of the stomach 
pain may be referred to the back, the chest, or the shoulder. The respira- 



598 



DISEASES OP THE DIGESTIVE SYSTEM. 



tion is superficial — costal in type — as it is painful to use the diaphragm. 
For the same reason the action of coughing is restrained, and even the 
movements necessary for talking are limited. In this early stage the sensi- 
tiveness may be great and the abdominal muscles are often rigidly con- 
tracted. If the patient is at perfect rest the pain may be very slight, and 
there are instances in which it is not at all marked, and may, indeed, be 
absent. 

The abdomen gradually becomes distended and tense and is tympanitic 
on percussion. The pulse is rapid, small, and hard, and often has a peculiar 
wiry quality. It ranges from 110 to 150. The temperature may rise rapid- 
ly after the chill and reach 104° or 105°, but the subsequent elevation is 
moderate. In some very severe cases there may be no fever throughout. 
The tongue at first is white and moist, but subsequently becomes dry and 
often red and fissured. Vomiting is an early and prominent feature and 
causes great pain. The contents of the stomach are first ejected, then a 
yellowish and bile-stained fluid, and finally a greenish and, in rare in- 
stances, a brownish-black liquid with slight faecal odor. The bowels may 
be loose at the onset and then constipation may follow. Frequent micturi- 
tion may be present, less often retention. The urine is usually scanty and 
high-colored, and contains a large quantity of indican. 

The appearance of the patient when these symptoms have fully devel- 
oped is very characteristic. The face is pinched, the eyes are sunken, and 
the expression is very anxious. The constant vomiting of fluids causes a 
wasted appearance, and the hands sometimes present the washer-woman's 
skin. Except in cholera, we see the Hippocratic facies more frequently 
in this than in any other disease — " a sharp nose, hollow eyes, collapsed 
temples; the ears cold, contracted, and their lobes turned out; the skin about 
the forehead being rough, distended, and parched; the color of the whole face 
being brown, black, livid, or lead-colored." There are one or two additional 
points about the abdomen. The tympany is usually excessive, owing to the 
great relaxation of the walls of the intestines by inflammation and exuda- 
tion. The splenic dulness may be obliterated, the diaphragm pushed up, 
and the apex beat of the heart dislocated to the fourth interspace. The 
liver dulness may be greatly reduced, or may, in the mammary line, be 
obliterated. It has been claimed that this is a distinctive feature of per- 
forative peritonitis, but on several occasions I have been able to demon- 
strate that the liver dulness in the middle and mammary line was obliter- 
ated by tympanites alone. In the axillary line, on the other hand, the 
liver dulness, though diminished, may persist. Pneumo-peritonamm fol- 
lowing perforation more certainly obliterates the hepatic dulness. In such 
cases the fluid effused produces a dulness in the lateral region; but with 
gas in the peritonaeum, if the patient is turned on the left side, a clear 
note is heard beneath the seventh and eighth ribs. Acute peritonitis may 
present a flat, rigid abdomen throughout its course. 

Effusion of fluid — ascites — is usually present except in some acute 
rapidly fatal cases. The flanks are dull on percussion. The dulness may 
be movable, though this depends altogether upon the degree of adhesions. 
There may be considerable effusion without either movable dulness or 



ACUTE GENERAL PERITONITIS. 



599 



fluctuation. A friction-rub may be present, as first pointed out by Bright, 
but it is not nearly so common in acute as in chronic peritonitis. 

Course. — The acute diffuse peritonitis usually terminates in death. 
The most intense forms may kill within thirty-six to forty-eight hours; 
more commonly death results in four or five days, or the attack may be 
prolonged to eight or ten days. The pulse becomes irregular, the heart- 
sounds weak, the breathing shallow; there are lividity with pallor, a cold 
skin with high rectal temperature — a group of symptoms indicating pro- 
found failure of the vital functions for which Gee has revived the old term 
Upothymia. Occasionally death occurs with great suddenness, owing, pos- 
sibly, to paralysis of the heart. 

Diagnosis. — In typical cases the severe pain at onset, the distention 
of the abdomen, the tenderness, the fever, the gradual development of 
effusion, collapse symptoms, and the vomiting give a characteristic picture. 
Careful inquiries should at once be made concerning the previous condi- 
tion, from which a clew can often be had as to the starting-point of the 
trouble. In young adults a considerable proportion of all cases depends 
upon perforating appendicitis, and there may be an account of previous 
attacks of pain in the iliac region, or of constipation alternating with diar- 
rhoea. In women the most frequent causes are suppurative processes in 
the pelvic viscera, associated with salpingitis, abscesses in the broad liga- 
ments, or acute puerperal infection. Perforation of gastric ulcer is a more 
common factor in women than in men. It is not always easy to determine 
the cause. Many cases come under observation for the first time with the 
abdomen distended and tender, and it is impossible to make a satisfactory 
examination. In such instances the pelvic organs should be examined 
with the greatest care. In typhoid fever, if the patient is conscious,, the 
sudden onset of pain, the development of great meteorism, and the aggra- 
vation of the general symptoms indicate clearly what has happened. When 
the patient is in deep coma, on the other hand, the perforation may be 
overlooked. The following conditions are most apt to be mistaken for 
acute peritonitis: 

(a) Acute Entero-colitis. — Here the pain and distention and the sen- 
sitiveness on pressure may be marked. The pain is more colicky in char- 
acter, the diarrhoea is more frequent, and the collapse is more extreme. 

(h) The So-called Hysterical Peritonitis. — This has deceived the very 
elect, as almost every feature of genuine peritonitis, even the collapse, may 
be simulated. The onset may be sudden, with severe pain in the abdomen, 
tenderness, vomiting, diarrhoea, difficulty in micturition, and the charac- 
teristic decubitus. Even the temperature may be elevated. There may be 
recurrence of the attack. A case has been reported by Bristowe in which 
lour attacks occurred within a year, and it was not until special hysterical 
symptoms developed that the true nature of the trouble was suspected. 

(c) Obstruction of the towel, as already mentioned, may simulate peri- 
tonitis, both having pain, vomiting, tympanites, and constipation in com- 
mon. It may for a couple of days really be impossible to make a diagnosis 
in the absence of a satisfactory history. 

((I) Rupture of an abdominal aneurism or embolism of the superior 



600 



DISEASES OF THE DIGESTIVE SYSTEM. 



mesenteric artery may cause symptoms which simulate peritonitis. In the 
latter, sudden onset with severe pain, the collapse symptoms, frequent 
vomiting, and great distention of the abdomen may be present. 

(e) I have already referred to the fact that acute hemorrhagic pan- 
creatitis may be mistaken for peritonitis. , Lastly, a ruptured tubal preg- 
nancy may resemble acute peritonitis. 



II. PERITONITIS IN INFANTS. 

Peritonitis may occur in the foetus as a consequence of syphilis, and 
may leac> to constriction of the bowel by fibrous adhesions. 

In the new-born a septic peritonitis may extend from an inflamed cord. 
Distention of the abdomen, slight swelling and redness about the cord, and 
not infrequently jaundice are present. It is an uncommon event, and 
existed in only 4 of 51 infants dying with inflammation of the cord and 
.septicaemia (Eunge). 

During childhood peritonitis develops from causes similar to those af- 
fecting the adult. Perforative appendicitis is common. Peritonitis fol- 
lowing blows or kicks on the abdomen occurs more frequently at this 
period. In boys injury while playing foot-ball may be followed by diffuse 
peritonitis. A rare cause in children is extension through the diaphragm 
from an empyema. There are on record instances of peritonitis occurring 
in several children at the same school, and it has been attributed to sewer- 
gas poisoning. It was in investigating an epidemic of this kind at the 
Wandsworth school, in London, that Anstie received the post-mortem 
-wound of which he died. 



III. LOCALIZED PERITONITIS. 

1. Subphrenic Peritonitis. — The general peritonaeum covering the right 
:and left lobes of the liver may be involved in an extension from the pleura 
•of suppurative, tuberculous, or cancerous processes. In various affections 
of the liver — cancer, abscess, hydatid disease, and in affections of the 
gall-bladder — the inflammation may be localized to the peritonaeum cover- 
ing the upper surface of the organ. These forms of localized subphrenic 
peritonitis in the greater sac are not so important in reality as those which 
•occur in the lesser peritonaeum. The anatomical relations of this struc- 
ture are as follows: It lies behind and below the stomach, the gastro- 
hepatic omentum, and the anterior layer of the great omentum. Its 
lower limit forms the upper layer of the transverse meso-colon. On either 
side it reaches from the hepatic to the splenic flexure of the colon, and 
from the foramen of Winslow to the hilus of the spleen. Behind it cov- 
ers and is tightly adherent to the front of the pancreas. Its upper limit 
is formed by the transverse fissure of the liver, and by that portion of the 
•diaphragm which is covered by the lower layer of the right lateral liga- 
ment of the liver; the lobus Spigelii lies bare in the cavity. The foramen 



LOCALIZED PERITONITIS. 



601 



•of Winslow, through which the lesser communicates with the greater peri- 
tonaeum, is readily closed by inflammation. 

Inflammatory processes, exudates, and haemorrhages may be confined 
entirely to the lesser peritonaeum. The exudate of tuberculous peritonitis 
may be confined to it. Perforations of certain parts of the stomach, of 
the duodenum, and of the colon may excite inflammation in it alone; and 
in various affections of the pancreas, particularly trauma and haemorrhage, 
the effusion into the sac has often been confounded with cyst of this organ. 
" Pathological distention of the lesser peritonaeum gives rise to a tumor 
in the left hypochondriac, epigastric, and umbilical regions of a somewhat 
characteristic shape, but which appears to vary from time to time in form 
and size, according to the conditions of the overlying stomach; for when 
the viscns is full of liquid contents it increases the area of the tumor's 
dulness, while it makes its outlines less definable by palpation, and if the 
stomach is distended with gas the dull area becomes resonant and apparent- 
ly the tumor may disappear altogether. The colon always lies below the 
tumor and never in front of or above it, as is the case in kidney enlarge- 
ment " (Jordan Lloyd). 

Special mention must be made of the remarkable form of subphrenic 
abscess containing air, which may simulate closely pneumothorax, and 
hence was called by Leyden Pyo-pneumotlwrax subplirenicus. The affection 
has been thoroughly studied of late years by Scheurlen, Mason, Meltzer, 
and Lee Dickinson. In 142 out of 170 recorded cases the cause was known. 
In a few instances, as in one reported by Meltzer, the subphrenic abscess 
seemed to have followed pneumonia. Pyothorax is an occasional cause. 
By far the most frequent condition is gastric ulcer, which occurred in 80 
of the cases. Duodenal ulcer was the cause in 6 per cent. In about 10 
per cent of the cases the appendix was the starting-point of the abscess. 
■Cancer of the stomach is an occasional cause. Other rare causes are trauma, 
which was present in one of my cases, perforation of an hepatic or a renal 
abscess, lesions of the spleen, abscess, and cysts of the pancreas. 

In a majority of all the cases in which the stomach or duodenum is per- 
forated — sometimes, indeed, in the cases following trauma, as in Case 3 
of my series — the abscess contains air. 

The symptoms of subphrenic abscess vary very considerably, depending 
a good deal upon the primary cause. The onset, as a rule, is abrupt, par- 
ticularly when due to perforation of a gastric ulcer. There are severe 
pain, vomiting, often of bilious or of bloody material; respiration is em- 
barrassed, owing to the involvement of the diaphragm; then the constitu- 
tional symptoms develop associated with suppuration, chills, irregular 
Eever, and emaciation. Subsequently perforation may take place into the 
pleura or into the lung, with severe cough and abundant purulent ex- 
pectoration. 

The conditions are so obscure that the diagnosis of subphrenic abscess 
is not often made. The perihepatic abscess beneath the arch of the dia- 
phragm, whether to the right or left of the suspensory ligament, when it 
does not contain air, is almost invariably mistaken for empyema. When a 
pus collection of any size is in the lesser peritonaeum, the tumor is formed 



602 



DISEASES OF THE DIGESTIVE SYSTEM. 



which has the characters already mentioned in a quotation from Mr. Jor- 
dan Lloyd. 

The most remarkable features are those which are superadded when 
the abscess cavity contains air. Here, on the right side, when the abscess 
is in the greater peritonaeum, above the right lobe of the liver, the dia- 
phragm may be pushed up to the level of the second or third rib, and the 
physical signs on percussion and auscultation are those of pneumothorax, 
particularly the tympanitic resonance and the movable dulness. The liver 
is usually greatly depressed and there is bulging on the right side. Still 
more obscure are the cases of air-containing abscesses due to perforation 
of the stomach or duodenum, in which the gas is contained in the lesser 
peritonaeum. Here the diaphragm is pushed up and there are signs of 
pneumothorax on the left side. In a large majority of all the cases 
which follow perforation of a gastric ulcer the effusion lies between the 
diaphragm above, and the spleen, stomach, and the left lobe of the liver 
below. 

The prognosis in subphrenic abscess is not very hopeful. Of the cases 
on record about 20 per cent only have recovered. Of the five cases which 
have come under my observation, three recovered after operation. 

2. Appendicular. — The most frequent cause in the male of localized 
peritonitis is inflammation of the appendix vermiformis. The situation 
varies with the position of this extremely variable organ. The adhesion, 
perforation, and intraperitoneal abscess cavity may be within the pelvis, 
or to the left of the median line in the iliac region, in the lower right 
quadrant of the umbilical region — a not uncommon situation — or, of course, 
most frequently in the right iliac fossa. In the most common situation 
the localized abscess lies upon the psoas muscle, bounded by the caecum 
on the right and the terminal portion of the ileum and its mesentery in 
front and to the left. In many of these cases the limitation is perfect, 
and post-mortem records show that complete healing may take place with 
the obliteration of the appendix in a mass of firm scar tissue. 

3. Pelvic Peritonitis. — The most frequent cause is inflammation about 
the uterus and Fallopian tubes. Puerperal septicaemia, gonorrhoea, and 
tuberculosis are the usual causes. The tubes are the starting-point in a 
majority of the cases. The fimbriae become adherent and closely matted 
to the ovary, and there is gradually produced a condition of thickening of 
the parts, in which the individual organs are scarcely recognizable. The 
tubes are dilated and filled with cheesy matter or pus, and there may be 
small abscess cavities in the broad ligaments. Rupture of one of these may 
cause general peritonitis, or the membrane may be involved by extension, 
as in tuberculosis of these parts. 



IV. CHRONIC PERITONITIS. 

The following varieties may be recognized: (a) Local adhesive perito- 
nitis, a very common condition, which occurs particularly about the spleen, 
forming adhesions between the capsule and the diaphragm, about the liver, 



CHRONIC PERITONITIS. 



603 



less frequently about the intestines and mesentery. Points of thickening 
or puckering on the peritonaeum occur sometimes with union of the coils 
or with fibrous bands. In a majority of such cases the condition is met 
accidentally post mortem. Two sets of symptoms may, however, be caused 
by these adhesions. When a fibrous band is attached in such a way as 
to form a loop or snare, a coil of intestine may pass through it. Thus, 
of the 295 cases of intestinal obstruction analyzed by Fitz, 63 were due to 
this cause. The second group is less serious and comprises cases with per- 
sistent abdominal pain of a colicky character, sometimes rendering life mis- 
erable. Instances of this kind have been successfully operated upon by 
Homans and H. A. Kelly. 

(b) Diffuse Adhesive Peritonitis. — This is a consequence of an acute in- 
flammation, either simple or tuberculous. The peritonaeum is obliterated. 
On cutting through the abdominal wall, the coils of intestines are uni- 
formly matted together and can neither be separated from each other nor 
can the visceral and parietal layers be distinguished. There may be thick- 
ening of the layers, and the liver and spleen are usually involved in the 
adhesions. 

(c) Proliferative Peritonitis. — Apart from cancer and tubercle, which 
produce typical lesions of chronic peritonitis, the most characteristic form 
is that which may be described under this heading. The essential ana- 
tomical feature is great thickening of the peritoneal layers, usually without 
much adhesion. The cases are sometimes seen with sclerosis of the stom- 
ach. In one instance I found it in connection with a sclerotic condition 
of the caecum and the first part of the colon. In the inspection of a case 
of this kind there is usually moderate effusion, more rarely extensive ascites. 
The peritonaeum is opaque-white in color, and everywhere thickened, often 
in patches. The omentum is usually rolled and forms a thickened mass 
transversely placed between the stomach and the colon. The peritonaeum 
over the stomach, intestines, and mesentery is sometimes greatly thickened. 
The liver and spleen may simply be adherent, or there is a condition of 
chronic perihepatitis or perisplenitis, so that a layer of firm, almost gristly 
connective tissue of from one fourth to half an inch in thickness encircles 
these organs. Usually the volume of the liver is in consequence greatly 
Teduced. The gastro-hepatic omentum may be constricted by this new 
growth and the calibre of the portal vein much narrowed. A serous effu- 
sion may be present. On account of the adhesions which form, the peri- 
tonaeum may be divided into three or four different sacs, as is more fully 
described under the tuberculous peritonitis. In these cases the intestines 
are usually free, though the mesentery is greatly shortened. There are in- 
stances of chronic peritonitis in which the mesentery is so shortened by 
this proliferative change that the intestines form a ball not larger than a 
cocoa-nut situated in the middle line, and after the removal of the exuda- 
tion can be felt as a solid tumor. The intestinal wall is greatly thickened 
and ! ho mucous membrane of the ileum is thrown into folds like the valvule 
conniventes. This proliferative peritonitis is found frequently in the sub- 
jects of chronic alcoholism. In cases of long-continued ascites the serous 
surfaces generally become thickened and present an opaque, dead-white 



601 



DISEASES OF THE DIGESTIVE SYSTEM. 



color. This condition is observed especially in hepatic cirrhosis, but attends 
tumors, chronic passive congestions, etc. 

In all forms of chronic peritonitis a friction may be felt usually in the 
upper zone of the abdomen. Polyorrhomenitis, polyserositis, general 
chronic inflammation of the serous membranes, may occur with this form 
as well as in the tuberculous variety. The pericardium and both pleura? 
may be involved. 

In some instances of chronic peritonitis the membrane presents numer- 
ous nodular thickenings, which may be mistaken for tubercles. J. F. 
Payne has described a case of this sort associated with disseminated 
growths throughout the liver which were not cancerous. It has been 
suggested that some of the cases of tuberculous peritonitis cured by oper- 
ation have been of this nature, but histological examination would, as 
a rule, readily determine between the conditions. Miura, in Japan, has 
reported a case in which these nodules contained the ova of a parasite. One 
case has been reported in which the exciting cause was regarded as choles- 
terin plates, which were contained within the granulomatous nodules. 

(d) Chronic Hemorrhagic Peritonitis. — Blood-stained effusions in the 
peritonaeum occur particularly in cancerous and tuberculous disease. There 
is a form of chronic inflammation analogous to the haemorrhagic pachymen- 
ingitis of the brain. It was described first by Virchow, and is localized 
most commonly in the pelvis. Layers of new connective tissue form on 
the surface of the peritonaeum with large wide vessels from which haemor- 
rhage occurs. This is repeated from time to time with the formation of 
regular layers of haemorrhagic effusion. It is rarely diffuse, more com- 
monly circumscribed. 



V. NEW GROWTHS IN THE PERITON/EUM. 

(a) Tuberculous Peritonitis. — This has already been considered. 

(b) Cancer of the Peritonaeum. — Although, as a rule, secondary to disease 
of the stomach, liver, or pelvic organs, cases of primary cancer have been 
described. It is probable that the so-called primary cancers of the serous 
membranes are endotheliomata and not carcinomata. Secondary malig- 
nant peritonitis occurs in connection with all forms of cancer. It is usually 
characterized by a number of round tumors scattered over the entire peri- 
tonaeum, sometimes small and miliary, at other times large and nodular, 
with puckered centres. The disease most commonly starts from the stom- 
ach or the ovaries. The omentum is indurated, and, as in tuberculous 
peritonitis, forms a mass which lies transversely across the upper portion 
of the abdomen. Primary malignant disease of the peritonaeum is extremely 
rare. Colloid is said to have occurred, forming enormous masses, which in 
one case weighed over 100 pounds. Cancer of this membrane spreads, 
either by the detachment of small particles which are carried in the lymph 
currents and by the movements to distant parts, or by contact of opposing* 
surfaces. It occurs more frequently in women than in men, and more com- 
monly at the later period of life. 

The diagnosis of cancer of the peritonaeum is easy with a history of a 



ASCITES. 



605 



local malignant disease; as when it occurs with ovarian tumor or with 
cancer of the pylorus. In cases in which there is no evidence of a primary 
lesion the diagnosis may be doubtful. The clinical picture is usually that 
of chronic ascites with progressive emaciation. There may be no fever. 
If there is much effusion nothing definite can be felt on examination. After 
tapping, irregular nodules or the curled omentum may be felt lying trans- 
versely across the upper portion of the abdomen. Unfortunately, this tumor 
upon which so much stress is laid occurs as frequently in tuberculous peri- 
tonitis and may be present in a typical manner in the chronic proliferative 
form, so that in itself it has no special diagnostic value. Multiple nodules, 
if large, indicate cancer, particularly in persons above middle life. Nodu- 
lar tuberculous peritonitis is most frequent in children. The presence 
about the navel of secondary nodules and indurated masses is more com- 
mon in cancer. Inflammation, suppuration, and the discharge of pus from 
the navel rarely occurs except in tuberculous disease. Considerable en- 
largement of the inguinal glands may be present in cancer. The nature 
of the fluid in cancer and in tubercle may be much alike. It may be hemor- 
rhagic in both; more often in the latter. The histological examination in 
cancer may show large multinuclear cells or groups of cells — the sprouting 
cell-groups of Foulis — which are extremely suggestive. The colloid cancer 
may produce a totally different picture; instead of ascitic fluid, the abdo- 
men is occupied by the semi-solid gelatinous substance, and is firm, not 
fluctuating. 

And, lastly, there are instances of echinococci in the peritoneum which 
may simulate cancer very closely. I have reported a case of this kind, in 
which the enlarged liver and the innumerable nodular masses in the peri- 
toneum naturally led to this diagnosis. 



VI. ASCITES (Hydro-peritonceum). * 

Definition. — The accumulation of serous fluid in the peritoneal cavity. 

Etiology. — (1) Local Causes. — (a) Chronic inflammation of the peri- 
toneum, either simple, cancerous, or tuberculous, (b) Portal obstruction in 
the terminal branches within the liver, as in cirrhosis and chronic passive 
congestion, or by compression of the vein in the gastro-hepatic omentum, 
either by proliferative peritonitis, by new growths, or by aneurism, (c) 
Tumors of the abdomen. The solid growths of the ovaries may cause con- 
siderable ascites, which may completely mask the true condition. The en- 
larged spleen in leukemia, less commonly in malaria, may be associated 
with recurring ascites. 

(2) General Causes.— The ascites is part of a general dropsy, the result 
of mechanical effects, as in heart-disease, chronic emphysema, and sclerosis 
of the Lung. In cardiac lesions the effusion is sometimes confined to the 
peritonaeum, in which case it is due to secondary changes in the liver, or it 
has been suggested to be connected with a failure of the suction action of 
this organ, by which the peritoneum is kept dry. Ascites occurs also in 
the dropsy of Bright's disease, and in hydremic states of the blood. 



606 



DISEASES OF THE DIGESTIVE SYSTEM. 



Symptoms. — A gradual uniform enlargement of the abdomen is the 
characteristic symptom of ascites. The physical signs are usually distinctive, 
(a) Inspection. — According to the amount of fluid the abdomen is pro- 
tuberant and flattened at the sides. With large effusions, the skin is tense 
and may present the linea? albicantes. Frequently the navel itself and the 
parts about it are very prominent. In many cases the superficial veins are 
enlarged and a plexus joining the mammary vessels can be seen. Sometimes 
it can be determined by pressure on these veins that the current is from 
below upward. In some instances, as in thrombosis or obliteration of the 
portal vein, these superficial abdominal vessels may be extensively varicose. 
About the navel in cases of cirrhosis there is occasionally a large bunch of 
distended veins, the so-called caput Medusa?. 

(b) Palpation. — Fluctuation is obtained by placing the fingers, of one 
hand upon one side of the abdomen and by giving a sharp tap on the op- 
posite side with the other hand, when a wave is felt to strike as a definite 
shock against the applied fingers. Even comparatively small quantities of 
fluid may give this fluctuation shock. When the abdominal walls are 
thick or very fat, an assistant may place the edge of the hand or a piece 
of cardboard in the front of the abdomen. A different procedure is 
adopted in palpating for the solid organs in case of ascites. Instead of plac- 
ing the hand flat upon the abdomen, as in the ordinary method, the pads 
of the fingers only are placed lightly upon the skin, and then by a sudden 
depression of the fingers the fluid is displaced and the solid organ or tumor 
may be felt. By this method of " dipping " or displacement, as it is called, 
the liver may be felt below the costal margin, or the spleen, or sometimes 
solid tumors of the omentum or intestine. 

(c) Percussion. — In the dorsal position with a moderate quantity of 
fluid in the peritonaeum the flanks are dull, while the umbilical and epi- 
gastric regions, into which the intestines float, are tympanitic. This area 
of clear resonance may have an oval outline. Having obtained the lateral 
limit of the dulness on one side, if the patient turns on the opposite side, 
the fluid gravitates to the dependent part and the uppermost flank is 
now tympanitic. In moderate effusions this movable dulness changes great- 
ly in the different postures. Small amounts of fluid, probably under a 
litre, would scarcely give movable dulness, as the pelvis and the renal re- 
gions hold a considerable quantity. In such cases it is best to place the 
patient in the knee-elbow position, when a dull note will be determined at 
the most dependent portion. By careful attention to these details mis- 
takes are usually avoided. 

The following are among the conditions which may be mistaken for 
dropsy: Ovarian tumor, in which the sac develops, as a rule, unilaterally, 
though when large it is centrally placed. The dulness is anterior and the 
resonance is in the flanks, into which the intestines are pushed by the cyst. 
Examination per vaginam may give important indications. In those rare 
instances in which gas develops in the cyst the diagnosis may be very diffi- 
cult. Succussion has been obtained in such cases. A distended bladder 
may reach above the umbilicus. In such instances some urine dribbles 
away, and suspicion of ascites or a cyst is occasionally entertained. I once 



ASCITES. 



607 



saw a trochar thrust into a distended bladder, which was supposed to be 
an ovarian cyst, and it is stated that John Hunter tapped a bladder, sup- 
posing it to be ascites. Such a mistake should be avoided by careful 
catheterization prior to any operative procedures. And lastly, there are 
large pancreatic or hydatid cysts in the abdomen which may simulate ascites. 

Nature of the Ascitic Fluid. — Usually this is a clear serum, light yel- 
low in the ascites of anaemia and Bright's disease, often darker in color in 
cirrhosis of the liver. The specific gravity is low, seldom more than 1.010 
or 1.015, whereas in the fluid of ovarian cysts the specific gravity is high, 
1,020 or over. It is albuminous and sometimes coagulates spontaneously. 
Dock has called attention to the importance of the study of the cells in 
the exudate. In cancer very characteristic forms, with nuclear figures, may 
be found. Hemorrhagic effusion usually occurs in cancer and tubercu- 
losis, and occasionally in cirrhosis. I have already referred to the in- 
stances of hemorrhagic effusion in connection with ruptured tubal preg- 
nancy. A chylous, milky exudate is occasionally found. Busey has col- 
lected 33 cases from the literature. There are, as Quincke has pointed out, 
two distinct varieties, a fatty and a chylous, which may be distinguished 
by the microscope, as in the former there are distinct fat-globules. These 
cases have been sometimes connected with peritoneal or mesenteric cancer. 
In the true chylous ascites the fluid is turbid and milky. In some of the 
cases, as in Whitla's, a perforation of the thoracic duct has been found. 
The condition does not necessarily follow obliteration of the thoracic duct. 
Mild grades of chylous ascites, which are occasionally found clinically, may 
be due to the fact that the patient upon a milk diet has a permanent 
lipaemia, such as is present in young animals and in diabetics, in whom the 
liquor sanguinis is always fatty. Under such circumstances an exudate 
may contain enough of the molecular base of the chyle to produce turbid- 
ity of the fluid. Some of the cases have been associated with filariasis. 
In a recent case in my clinic N. McL. Harris isolated the bacillus diph- 
theria? from the chylous fluid. 

Treatment of the Previous Conditions.— (a) Acute Peri- 
tonitis. — Rest is enjoined upon the patient by the severe pain which fol- 
lows the slightest movement, and he should be propped in the position 
which gives him greatest relief. For the pain morphia should be injected 
hypodermically in full doses. In an adult it is better to give a third or 
half a grain at once, and subsequently at intervals repeat it in smaller 
doses, when necessary. The action of the drug should be carefully 
watched and the patient should not be allowed to pass into such a degree 
of unconsciousness that he cannot be aroused. The respiration and the 
condition of the pupils also give valuable information. The amount of 
opium which has been given in certain instances is remarkable, and indi- 
cates a tolerance of the drug. The doses given by the late Alonzo Clark, 
of New York, may be truly termed heroic. Austin Flint notes that a pa- 
tienl under the care of this physician took "in the first twenty-four hours, 
of opium and the sulphate of morphia, a quantity equivalent to 10G grains 
of opium; in the second twenty-four hours she took 472 grains; on the 
third day, 236 grains; on the fourth day, 120 grains; on the fifth day, 
38 



608 



DISEASES OF THE DIGESTIVE SYSTEM. 



54 grains; on the sixth day, 22 grains; on the seventh day, 18 grains; after 
which the treatment was suspended." It is unnecessary to use these enor- 
mous doses, as, even when the pain is most intense, from a third to a half 
grain of morphia every few hours will usually keep the patient thoroughly 
under the influence of the drug. In a robust, strong patient, seen at the 
outset, twenty leeches applied over the abdomen will give great relief. 

Local applications — either hot turpentine stupes or cloths wrung out 
of ice-water — may be laid upon the abdomen. The patients sometimes 
declare that they are greatly relieved by the latter. 

The question of the use of purgatives in peritonitis has of late been 
warmly discussed. Lawson Tait and other gynaecologists have used the 
saline purges with the greatest benefit in post-operation peritonitis. Theo- 
retically it appears correct to give salines in concentrated form, which 
cause a rapid and profuse exosmosis of serum from the intestinal vessels, 
relieving the congestion and reducing the oedema, which is one important 
factor in causing the meteorism. It is also urged that the increased peri- 
stalsis prevents the formation of adhesions. In reading the reports of these 
successful cases, one is not always convinced, however, that peritonitis 
actually existed. Still, in cases of acute peritonitis due to extension or 
following operation or in septic conditions the judgment of many careful 
men is decidedly in favor of the use of salines. I cannot speak from per- 
sonal experience on this question. The majority of cases of peritonitis 
which come under the care of the physician follow lesions of the abdominal 
viscera or are due to perforation of ulcer of the stomach, the ileum, or the 
appendix. ' In such cases, particularly in the large group of appendix cases, 
to give saline purgatives is, to say the least, most injudicious treatment. 
The safety of the patient lies in the restriction of the peristalsis and the 
localization of the inflammation, for which purpose opium alone is of 
service. In these instances rectal injections should be employed to relieve 
the large bowel. ISTo symptom in acute peritonitis is more serious than 
the tympanites, and none is more difficult to meet. The use of the long 
tube and injections containing turpentine may be tried. Drugs by the 
mouth cannot be retained. 

For the vomiting, ice and small quantities of soda water may be em- 
ployed. The patient should be fed on milk, but if the vomiting is dis- 
tressing it is best not to attempt to give food by the mouth, but to use 
small nutrient enemata. In all cases of peritonitis it is best to have a sur- 
geon in consultation early in the disease, as the question of operation may 
come up at any moment. I have already mentioned the conditions under 
which laparotomy is indicated in perforative appendicitis. The acute 
purulent cases, particularly those in which the streptococci occur, usually 
die; but the results of operative interference even in this form are steadily 
improving. In the acute forms of tuberculous peritonitis operative meas- 
ures appear to be more hopeful, but they are not always successful. 

(b) Chronic Peritonitis. — For the cases of chronic proliferative peri- 
tonitis very little can be done. The treatment is practically that of ascites. 
In all these forms, when the distention becomes extreme, tapping is indi- 
cated. The treatment of tuberculous peritonitis has fallen largely into 



ASCITES. 



609 



the hands of the surgeons, and the results in many cases are very good. 
According to the statistics of Maurange,* of 71 cases, 28 survived the opera- 
tion for more than a year. Of 26 additional cases which I have collected,! 
14 were dead at the time of the report. Within two years and three months 
there were 6 operations performed at the Johns Hopkins Hospital in tuber- 
culous peritonitis, with 4 recoveries. Maurice Eichardson, in a child aged 
five, with a suspected appendicitis (tumor, etc.), found the symptoms to 
be due to enlarged, tuberculous mesenteric glands, which were removed, 
and the boy remained well five years after the operation (Phila. Med. Jr., 
1890, ii). 

(c) Ascites. — The treatment depends somewhat on the nature of the 
case. In cirrhosis early and repeated tapping may give time for the estab- 
lishment of the collateral circulation, and temporary cures have followed 
this precedure. Permanent drainage with Southey's tube, incision, and 
washing out the peritonaeum have also been practised. In the ascites 
of cardiac and renal disease the cathartics are most satisfactory, particularly 
the bitartrate of potash, given alone or with jalap, and the large doses of 
salts given an hour before breakfast with as little water as possible. These 
sometimes cause rapid disappearance of the effusion, but they are not so 
successful in ascites as in pleurisy with effusion. The stronger cathartics 
may sometimes be necessary. The ascites forming part of the general 
anasarca of Bright's disease will receive consideration under another sec- 
tion. 



* Paris Thesis, 1889. 

f On Tuberculous Peritonitis, Johns Hopkins Hospital Reports, 1890. 



SECTION VI. 

DISEASES OF THE EESPIRATOET SYSTEM. 

I. DISEASES OF THE JSTOSE. 
I. ACUTE CORYZA. 

Acute catarrhal inflammation of the upper air-passages, popularly 
known as a " catarrh " or a " cold," is usually an independent affection, 
hut may precede the development of another disease. 

Etiology. — It prevails most extensively in the changeable weather of 
the spring and early winter, and may occur in epidemic form, many cases 
developing in a community within a few weeks. These outbreaks are 
very like, though less intense than the epidemic influenza, cases of which 
may begin with symptoms of ordinary coryza. The disease probably de- 
pends upon a micro-organism. Irritating fumes, such as those of iodine or 
ammonia, also may cause an acute catarrh of the nose. 

Symptoms. — The patient feels indisposed, perhaps chilly, has slight 
headache, and sneezes frequently. In severe cases there are pains in the 
back and limbs. There is usually slight fever, the temperature rising to 
101°. The pulse is quick, the skin is dry, and there are all the features of 
a feverish attack. At first the mucous membrane of the nose is swollen, 
" stuffed up," and the patient has to breathe through the mouth. A thin, 
clear, irritating secretion flows, and makes the edges of the nostrils sore. 
The mucous membrane of the tear-ducts is swollen, so that the eyes weep 
and the conjunctivae are injected. The sense of smell and, in part, the 
sense of taste is lost. With the nasal catarrh there is slight soreness of 
the throat and stiffness of the neck; the pharynx looks red and swollen, 
and sometimes the act of swallowing is painful. The larynx also may be 
involved, and the voice becomes husky or is even lost. If the inflamma- 
tion extends to the Eustachian tubes there may be impairment of the 
hearing. In more severe cases there are bronchial irritation and cough. 
Occasionally there is an outbreak of labial or nasal herpes. Usually within 
thirty-six hours the nasal secretion becomes turbid and more profuse, the 
swelling of the mucosa subsides, the patient gradually becomes able to 
breathe through the nostrils, and within four or five days the symptoms 
disapppear, with the exception of the increased discharge from the nose 
610 



CHEONIC NASAL CATARRH. 



611 



and upper pharynx. There are rarely any bad effects from a simple coryza. 
When the attacks are frequently repeated the disease may become chronic. 

The diagnosis is always easy, but caution must be exercised lest the 
initial catarrh of measles or severe influenza should be mistaken for the 
simple coryza. 

Treatment. — Many cases are so mild that the patients are able to be 
about and to attend to their work. If there are fever and constitutional 
disturbance, the patient should be kept in bed and should take a simple 
fever mixture, and at night a drink of hot lemonade and a full dose of 
Dover's powder. Many persons find great benefit from the Turkish bath. 
For the distressing sense of tightness and pain over the frontal sinuses, 
cocaine is very useful and sometimes gives immediate relief. The 4-per- 
cent solution may be injected into the nostrils, or cotton-wool soaked in 
it may be inserted into them. Later, the snuff recommended by Ferrier 
is advantageous, composed, as it is, of morphia (gr. ij), bismuth (3 iv), 
acacia powder (3 ij). This may occasionally be blown or snuffed into the 
nostrils. The fluid extract of hamamelis, " snuffed " from the hand every 
two or three hours, is much better. 

II. CHRONIC NASAL CATARRH. 

{Rhinitis ; Rhinitis hypertrophica ; Rhinitis atrophica). 

In simple chronic catarrh there is increased irritability of the mucous 
membrane, particularly of the erectile tissue on the septum and turbinated 
bones. There is a tendency to frequent stoppage of one or both nostrils 
and the patient very easily catches cold. The secretion is at first clear 
and afterward thick and tenacious. The sense of smell is not specially 
disturbed at this stage. With the mirror the mucous membrane looks 
congested and swollen and the veins may be distended. 

In hypertrophic rhinitis, which is usually a sequel of the former con- 
dition, the nasal passages are obstructed, chiefly by enlargement of the 
lower turbinated bodies and swelling of the mucous membrane of the sep- 
tum. Very often there is hypertrophy of the adenoid tissue in the vault 
of the pharynx and of the mucous membrane about the orifices of the 
Eustachian tubes. The two conditions frequently go together as expressed 
in the designation, chronic naso-pharyngeal catarrh. The symptoms of 
this hypertrophic rhinitis may be local or general. 

The most important local symptom is the obstruction of the passage of 
air through the nostrils, so that the patients become mouth-breathers. 
During the day this may not be very distressing, but at night the mouth 
and throat get extremely dry and the sleep is disturbed. The voice be- 
comes aasal in quality and in advanced cases, when the Eustachian tubes 
are obstructed, there may be deafness. It should ever be borne in mind by 
the practitioner that a very large proportion of all cases of deafness origi- 
nate in chronic naso-pharyngeal catarrh. The general symptoms have 
boon considered more fully under chronic pharyngeal catarrh and mouth- 
breathing. 



612 



DISEASES OF THE RESPIRATORY SYSTEM. 



Atropine rhinitis, which is also known under the names coryza fetida 
and ozaena, may be a sequence of the hypertrophic form. Ozsena is only a 
symptom, and is met with in many ulcerative conditions of the nostrils, 
particularly as a result of syphilis, foreign bodies, caries and necrosis of 
the bones, and glanders. Fortunately, the atrophic form by no means 
necessarily follows the hypertrophic stage. The cases are much more fre- 
quent in women than in men, and usually occur early in life. The mucous 
membrane is thin and covered with grayish crusts which, when removed, 
show a slightly excoriated surface, but true ulcers are rarely seen. The 
erectile tissue is completely atrophied by a process of slow connective-tissue 
growth, or, as J. N. Mackenzie calls it, a cirrhosis. The mucous mem- 
brane of the pharynx is usually dry and glazed. 

The symptoms are most distinctive, owing to the horrible odor which 
comes from the nose, and of which, fortunately, the patient is himself 
unconscious, because the sense of smell is lost. The secretion, which is 
puriform, dries and forms large crusts, which are dislodged by picking or 
which gradually fall off. The cause of the offensive odor has been much 
discussed — whether it is due to a special organism or to specially favorable 
conditions for the growth and development of the germs of putrefaction. 
Probably the latter view is correct. 

The treatment of hypertrophic rhinitis consists in the thorough cleans- 
ing of the nasal passages, the removal of the pharyngeal growths, and the 
reduction of the hypertrophied nasal mucosa. It is best to use a simple 
douche, in order to keep the membrane absolutely clean. The Birming- 
ham nasal douche is the most simple and satisfactory, and may be filled 
with alkaline and antiseptic or deodorizing solutions. One of the most 
satisfactory is the bicarbonate of soda (1-| drachm), listerine (6 drachms), 
and water (1 ounce). Operative procedures are necessary in a majority 
of the cases, and the practitioner should early call to his assistance the 
specialist. It is sad to think of the misery which has been entailed upon 
thousands of people owing to neglect of naso-pharyngeal catarrh by parents 
and physicians. 

The treatment of atrophic rhinitis comes more properly under the 
special monographs. 



III. AUTUMNAL CATARRH (Hay Fever). 

An affection of the upper air-passages, often associated with asthmatic 
attacks, due to the, action of certain stimuli upon a hypersensitive mucous 
membrane. 

This affection was first described in 1819 by Bostock, who called it 
catarrhus cestivus. Morrill Wyman, of Cambridge, Mass., wrote a mono- 
graph on the subject, and described two forms, the "June cold," or "rose 
cold/' which comes on in the spring, and the autumnal form which, in 
this country, does not develop until August and September, and never 
persists after a severe frost. Blakely studied its connection with the pol- 
len of various grasses and flowers. The late George M. Beard made many 



AUTUMNAL CATARRH. 



613 



careful observations on the disease. Until recently this form of catarrh 
was believed to result exclusively from the action of certain irritants on 
the mucous membrane of the nose, particularly the pollen of plants, 
which, as the experiments of Blakeley showed, play an important role in 
the disease. Other emanations also may induce an attack, as in the case 
of the late Austin Flint, who was liable to coryza, or even asthma, if he 
slept on a certain sort of feather pillow. This, however, is only one factor 
in the disease. A second, most important one, was discovered in the con- 
dition of the nasal mucous membrane in these cases. Voltolini, of Breslau, 
in 1871, observed the cure of a case of asthma by the removal of a nasal 
polypus. Since that date the observations of Hack, in Germany, and par- 
ticularly of Daly, of Pittsburg, Eoe, of Rochester, John N". Mackenzie, of 
Baltimore, and Harrison Allen, of Philadelphia, have demonstrated the 
association of asthmatic attacks with nasal disease. Daly discovered that 
in a large proportion of the cases of hay asthma there was local disease of 
the mucous membrane of the nose, the cure of which rendered the pa- 
tient insusceptible to conditions previously exciting the attacks. This has 
been abundantly confirmed. Still identical lesions exist in many people 
who never suffer with the disease, so that there must be a third factor, a 
neurotic constitution. In the etiology of hay fever, then, these three ele- 
ments prevail — a nervous constitution, an irritable nasal mucosa, and the 
stimulus. 

The disease affects certain families, particularly, it is said, those with a 
neurotic taint. The peculiarity may occur through several generations. 
It is certainly more common in the United States than in Europe, and 
much more common in the United States than in Canada. The United 
States Hay Fever Association now numbers thousands of members. 

Dwellers in cities are more subject than residents in the country. The 
structural peculiarities of the nasal mucous membrane are those of hyper- 
trophic rhinitis. Harrison Allen states that the inferior turbinated bones 
lie well above the floor of the nostrils, which renders the mucous mem- 
brane more liable to irritation from inhaled substances. Deflection of the 
septum, hypertrophy of the soft parts, and excessive hyperesthesia, so that 
the mere touch with a probe may be sufficient to induce an attack, are 
common conditions. 

Symptoms. — These are, in a majority of the cases, very like those of 
ordinary coryza. There may, however, be much more headache and dis- 
tress, and some patients become very low-spirited. Cough is a common 
symptom and may be very distressing. Paroxysms of asthma may develop, 
so like as to l)c indistinguishable from the ordinary bronchial form. The 
two conditions may indeed alternate, the patient having at one time an 
attack of common hay fever and at another, under similar circumstances, 
an attack of bronchial asthma. Of the immediate exciting causes of tin 1 
attack, unquestionably in a majority of the cases coming 0 n in the antnmn 
there is an association with the presence of pollen in the atmosphere, but 
this is only one of a host of exciting causes. Tn certain persons the parox- 
ysms may develop at any season from sudden changes in the temperature. 
An attack may even come on through association of ideas. The well- 



614 



DISEASES OF THE RESPIRATORY SYSTEM. 



known experiment of J. X. Mackenzie, of inducing an attack in a sus- 
ceptible person by offering her an artificial rose to smell, strikingly illus- 
trates the neurotic element in the disease. 

Treatment. — This may be comprised under three heads: First, since 
the disease appears in many instances to be a form of chronic neurosis, 
remedies which improve the stability of the nervous system may be em- 
ployed — such as arsenic, phosphorus, and strychnia. Second, climatic. 
Dwellers in the cities of the Atlantic seaboard and of the Central States 
enjoy complete immunity in the Adirondacks and White Mountains. As 
a rule the disease is aggravated by residence in agricultural districts. The 
dry mountain air is unquestionably the best; there are cases, however, which 
do well at the seaside. Third, the thorough local treatment of the nose, 
particularly the destruction of the vessels and sinuses over the sensitive 
areas. 

IV. EPISTAXIS. 

Etiology. — Bleeding from the nose may result from local, or consti- 
tutional conditions. Among local causes may be mentioned traumatism, 
small ulcers, picking or scratching the nose, new growths, and the presence 
of foreign bodies. In chronic nasal catarrh bleeding is not infrequent. 
The blood may come from one or both nostrils. The flow may be profuse 
after an injury. 

Among general conditions with which nose-bleeding is associated, the 
following are the most important: It occurs with great frequency in grow- 
ing children, particularly about the age of puberty; more frequently in 
the delicate than in the strong and vigorous. I have reported three cases 
of chronic recurring epistaxis in adults associated with remarkable telan- 
giectases of the skin and visible mueous membranes. 

Epistaxis is a very common event in persons of so-called plethoric 
habit. It is stated sometimes to precede, or to indicate a liability to, apo- 
plexy. There may be an hereditary tendency to it. 

In venous engorgement epistaxis is not common and there may be a 
most extreme grade of cyanosis without its occurrence. It is frequent in 
cirrhosis hepatis. In balloon and mountain ascensions, in the very rarefied 
atmosphere, haemorrhage from the nose is a common event. In haemo- 
philia the nose ranks first of the mucous membranes from which bleeding 
arises. It occurs in all forms of chronic anaemias. It precedes the onset 
of certain fevers, more particularly typhoid, with which it seems associated 
in a special manner. Vicarious epistaxis has been described in cases of 
suppression of the menses. Lastly, it is said to be brought on by certain 
psychical impressions, but the observations on this point are not trust- 
worthy. The blood in epistaxis results from capillary oozing or diapedesis. 
The mucous membrane is deeply congested and there are often capillary 
angiomata situated usually in the respiratory portion of the nostril and 
upon the cartilaginous septum. 

Symptoms. — Slight haemorrhage is not associated with any special 
features. When the bleeding is protracted the patients have the more 



ACUTE CATARRHAL LARYNGITIS. 



G15 



serious manifestations of loss of blood. In the slow dripping which, takes 
place in some instances of haemophilia, there may be formed a remarkable 
blood tumor projecting from one nostril and extending even below the 
mouth. 

Death from ordinary epistaxis is very rare. The more blood is lost, 
the greater is the tendency to clotting with spontaneous cessation of the 
bleeding. 

The diagnosis is usually easy. One point only need be mentioned; 
namely, that bleeding from the posterior nares occasionally occurs during 
sleep and the blood trickles into the pharynx and may be swallowed. If 
vomited, it may be confounded with haematemesis; or, if coughed up, with 
haemoptysis. 

Treatment. — In a majority of the cases the bleeding ceases of itself. 
Various simple measures may be employed, such as holding the arms 
above the head, the application of ice to the nose, or the injection of cold 
or hot water into the nostrils. Astringents, such as zinc, alum, or tannin, 
may be used; and the tincture of the perchloride of iron, diluted with ice- 
water, may be introduced into the nostrils. If the bleeding comes from 
an ulcerated surface, an attempt should be made to apply chromic acid or 
to cauterize. If the bleeding is at all severe and obstinate, the posterior 
nares should be plugged. Ergot may be given internally or hypodermically. 
The inhalation of carbonic-acid gas may be tried or a solution of gelatine 
or of adrenalin injected into the nostril. 



II. DISEASES OF THE LAEYKX. 
I. ACUTE CATARRHAL LARYNGITIS. 

This may come on as an independent affection or in association with 
general catarrh of the upper respiratory passages. 

Etiology. — Many cases are due to catching cold or to overuse of the 
voice; others develop in consequence of the inhalation of irritating gases. 
It may occur in the general catarrh associated with influenza and measles. 
Very severe laryngitis is excited by traumatism, either injuries from with- 
out or the lodgment of foreign bodies. It may be caused by the action of 
very hot liquids or corrosive poisons. 

Symptoms. — There is a sense of tickling referred to the larynx; the 
cold air irritates and, owing to the increased sensibility of the mucous mem- 
brane, the act of inspiration may be painful. There is a dry cough, and 
the voice is altered. At first it is simply husky, but soon phonation be- 
comes painful, and finally the voice may be completely lost. In adults the 
respirations are not increased in frequency, but in children dyspnoea is not 
uncommon and may occur in spasmodic attacks. If much oedema accom- 
panies the inflammatory swelling, there may be urgent dyspnoea. 

The laryngoscope shows a swollen and tumefied mucous membrane of 
the larynx, particularly the ary-epiglottidean folds. The vocal cords have 



616 



DISEASES OF THE RESPIRATORY SYSTEM. 



lost their smooth and shining appearance and are reddened and swollen. 
Their mobility also is greatly impaired, owing to the infiltration of the 
adjoining mucous membrane and of the muscles. A slight mucoid exuda- 
tion covers the parts. The constitutional symptoms are not severe. There 
is rarely much fever, and in many cases the patient is not seriously ill. Occa- 
sionally cases come on with greater intensity, the cough is very distressing, 
deglutition is painful, and there may be urgent dyspnoea. 

Diagnosis. — There is rarely any difficulty in determining the nature 
of a case if a satisfactory laryngoseopic examination can be made. The 
severer forms may simulate oedema of the glottis. When the loss of voice 
is marked, the case may be mistaken for one of nervous aphonia, but the 
laryngoscope would decide the question at once. Much more difficult is 
the diagnosis of acute laryngitis in children, particularly in the very young, 
in whom it is so hard to make a proper examination. From ordinary laryn- 
gismus it is to be distinguished by the presence of fever, the mode of onset, 
and particularly the coryza and the previous symptoms of hoarseness or loss 
of voice. Membranous laryngitis may at first be quite impossible to differ- 
entiate, but in a majority of cases of this affection there are patches on the 
pharynx and early swelling of the cervical glands. The symptoms, too, are 
much more severe. 

Treatment. — Best of the larynx should be enjoined, so far as phona- 
tion is concerned. In cases of any severity the patient should be kept 
in bed. The room should be at an even temperature and the air saturated 
with moisture. Early in the disease, if there is much fever, aconite and 
citrate of potash may be given, and for the irritating painful cough a full 
dose of Dover's powder at night. An ice-bag externally often gives great 
relief. 

II. CHRONIC LARYNGITIS. 

Etiology. — The ceases usually follow repeated acute attacks. The most 
common causes are overuse of the voice, particularly in persons whose occu- 
pation necessitates shouting in the open air. The constant inhalation of 
irritating substances, as tobacco-smoke, may also cause it. 

Symptoms. — The voice is usually hoarse and rough and in severe 
cases may be almost lost. There is usually very little pain; only the un- 
pleasant sense of tickling in the larynx, which causes a frequent desire to 
cough. With the laryngoscope the mucous membrane looks swollen, but 
much less red than in the acute condition. In association with the granu- 
lar pharyngitis, the mucous glands of the epiglottis and of the ventricles 
may be involved. 

Treatment. — The nostrils should be carefully examined, since in some 
instances chronic laryngitis is associated with and even dependent upon 
obstruction to the free passage of air through the nose. Local application 
must be made directly to the larynx, either with a brush or by means of a 
spray. Among the remedies most recommended are the solutions of nitrate 
of silver, chlorate of potash, perchloride of zinc, and tannic acid. Insuffla- 
tions of bismuth are sometimes useful. 



SPASMODIC LARYNGITIS. 



617 



Among directions to be given are the avoidance of heated rooms and 
loud speaking, and abstinence from tobacco and alcohol. The throat should 
not be too much muffled, and morning and evening the neck should be 
sponged with cold water. 



III. (EDEMATOUS LARYNGITIS. 

Etiology. — (Edema of the glottis, or, more correctly, of the structures 
which form the glottis, is a very serious affection which is met with (a) As 
a rare sequence of ordinary acute laryngitis. (&) In chronic diseases of the 
larynx, as syphilis or tubercle, (c) In severe inflammatory diseases like 
diphtheria, in erysipelas of the neck, and in various forms of cellulitis, (d) 
Occasionally in the acute infectious diseases — scarlet fever, typhus, or 
typhoid. In Bright's disease, either acute or chronic, there may be a rap- 
idly developing oedema, (e) In angio-neurotic oedema. 

Symptoms. — There is dyspnoea, increasing in intensity, so that with- 
in an hour or two the condition becomes very serious. There is sometimes 
marked stridor in respiration. The voice becomes husky and disappears. 
The laryngoscope shows enormous swelling of the epiglottis, which can 
sometimes be felt with the finger or even seen when the tongue is strongly 
depressed with a spatula. The ary-epiglottidean folds are the seat of the 
chief swelling and may almost meet in the middle line. Occasionally the 
oedema is below the true cords. 

The diagnosis is rarely difficult, inasmuch as even without the laryn- 
goscope the swollen epiglottis can be seen or felt with tiie finger. The 
disease is very fatal. 

Treatment. — An ice-bag should be placed on the larynx, and the pa- 
tient given ice to suck. If the symptoms are urgent, the throat should be 
sprayed with a strong solution of cocaine, and the swollen epiglottis scari- 
fied. If relief does not follow, tracheotomy should immediately be per- 
formed. The high rate of mortality is due to the fact that this operation 
is as a rule too long delayed. 



IV. SPASMODIC LARYNGITIS {Laryngismus stridulus). 

Spasm of the glottis is met with in many affections of the larynx, but 
there is a special disease in children which has received the above-mentioned 
and other names. 

Etiology. — A purely nervous affection, without any inflammatory con- 
dition of the larynx, it occurs in children between the ages of six months 
and three years, and is most commonly seen in connection with rickets. 
As Escherich has shown, the disease has close relations with tetany and 
may display many of the accessory phenomena of this disease. Often the 
attack comes on when the child has been crossed or scolded. Mothers 
sometimes call the attacks " passion fits " or attacks of " holding the 
breath." It was supposed at one time that they were associated with en- 



618 



DISEASES OF THE RESPIRATORY SYSTEM. 



largement of the thymus, and the condition therefore received the name 
of thymic asthma. 

The actual state of the larynx during a paroxysm is a spasm of the 
adductors, but the precise nature of the influences causing it is not yet 
known, whether centric or reflex from peripheral irritation. The disease 
is not so common in America as in England. 

Symptoms. — The attacks may come on either in the night or in the 
day; often just as the child awakes. There is no cough, no hoarseness, 
but the respiration is arrested and the child struggles for breath, the face 
gets congested, and then, with a sudden relaxation of the spasm, the air 
is drawn into the lungs with a high-pitched crowing sound, which has 
given to the affection the name of " child-crowing." Convulsions may 
occur during an attack or there may be carpo-pedal spasms. Death may, 
but rarely does, occur during the attack. With the cyanosis the spasm re- 
laxes and respiration begins. The attacks may recur with great frequency 
throughout the day. 

Treatment. — The gums should be carefully examined and, if swol- 
len and hot, freely lanced. The bowels should be carefully regulated, and 
as these children are usually delicate or rickety, nourishing diet and cod- 
liver oil should be given. By far the most satisfactory method of treat- 
ment is the cold sponging. In severe cases, two or three times a day the 
child should be placed in a warm bath and the back and chest thoroughly 
sponged for a minute or two with cold water. Since learning this practice 
from Einger, at the University Hospital, I have seen many cases in which 
it proved successful. It may be employed when the child is in a paroxysm, 
though if the attack is severe and the lividity is great it is much better to 
dash cold water into the face. Sometimes the introduction of the finger 
far back into the throat will relieve the spasm. 

Spasmodic croup, believed to be a functional spasm of the muscles of 
the larynx, is an affection seen most commonly between the ages of two and 
five years. According to Trousseau's description, the child goes to bed well, 
and about midnight or in the early morning hours awakes with oppressed 
breathing, harsh, croupy cough, and perhaps some huskiness of voice. The 
oppression and distress for a time are very serious, the face is congested, and 
there are signs of approaching cyanosis. The attack passes off abruptly, 
the child falls asleep and awakes the next morning feeling perfectly well. 
These attacks may be repeated for several nights in succession, and usually 
cause great alarm to the parents. Whether this is entirely a functional 
spasm is, I think, doubtful. There are instances in which the child is 
somewhat hoarse throughout the clay, and has slight catarrhal symptoms 
and a brazen, Aoupy cough. There is probably slight catarrhal laryngitis 
with it. These cases are not infrequently mistaken for true croup, and 
parents are sometimes unnecessarily disturbed by the serious view which 
the physician takes of the case. Too often the poor child, deluged with 
drugs, is longer in recovering from the treatment than he would be from 
the disease. To allay the spasm a whiff of chloroform may be administered, 
which will in a few moments give relief, or the child may be placed in a 
hot bath. A prompt emetic, such as zinc or wine of ipecac, will usually 



TUBERCULOUS LARYNGITIS. 



619 



relieve the spasm, and is specially indicated if the child has overloaded the 
stomach through the day. 

V. TUBERCULOUS LARYNGITIS. 

Etiology.' — Tubercles may develop primarily in the laryngeal mucosa, 
but in the great majority of cases the affection is secondary to pulmonary 
tuberculosis, in which it is met with in a variable proportion of from 18 
to 30 per cent. Laryngitis may occur very early in pulmonary tubercu- 
losis. There may be well-marked involvement of the larynx with signs of 
very limited trouble at one apex. These are cases which, in my experience, 
run a very unfavorable course. 

Morbid Anatomy. — The mucosa is at first swollen and presents scat- 
tered tubercles, which seem to begin in the neighborhood of the blood-ves- 
sels. By their fusion small tuberculous masses arise, which caseate and 
finally ulcerate, leaving shallow irregular losses of substance. The ulcers 
are usually covered with a grayish exudation, and there is a general thick- 
ening of the mucosa about them, which is particularly marked upon the 
arytenoids. The ulcers may erode the true cords and finally destroy them, 
and passing deeply may cause perichondritis with necrosis and occasionally 
exfoliation of the cartilages. The disease may extend laterally and involve 
the pharynx, and downward over the mucous membrane, covering the cri- 
coid cartilage toward the oesophagus. Above, it may reach the posterior 
wall of the pharynx, and in rare cases extend to the fauces and tonsils. 
The epiglottis may be entirely destroyed. There are rare instances in 
which cicatricial changes go on to such a degree that stenosis of the larynx 
is induced. 

Symptoms.' — The first indication is slight huskiness of the voice, 
which finally deepens to hoarseness, and in advanced stages there may be 
complete loss of voice. There is something very suggestive in the early 
hoarseness of tuberculous laryngitis. My attention has frequently been 
directed to the lungs simply by the quality of the voice. 

The cough is in part due to involvement of the larynx. Early in the 
disease it is not very troublesome, but when the ulceration is extensive it 
becomes husky and ineffectual. Of the symptoms of laryngeal tuberculo- 
sis, none is more aggravating than the dysphagia, which is met with par- 
ticularly when the epiglottis is involved, and when the ulceration has ex- 
tended to the pharynx. There is no more distressing or painful compli- 
cation in phthisis. In instances in which the epiglottis is in great part 
destroyed, with each attempt to take food there are distressing paroxysms 
of cough, and even of suffocation. 

With the laryngoscope there is seen early in the disease a pallor of the 
mucous membrane, which also looks thickened and infiltrated, particularly 
that covering the arytenoid cartilages. The tuberculous ulcers are very 
characteristic. They are broad and shallow, with gray bases and ill-defined 
outlines. The vocal cords are infiltrated and thickened, and ulceration is 
very common. 



620 



DISEASES OF THE RESPIRATORY SYSTEM. 



The diagnosis of tuberculous laryngitis is rarely difficult, as it is usually 
associated with well-marked pulmonary disease. In case of doubt some of 
the secretion from the base of an ulcer should be removed and examined for 
bacilli. ♦ 

Treatment. — Physicians pay scarcely sufficient attention to the laryn- 
geal complications of consumption. The ulcers should be sprayed and kept 
thoroughly cleansed. Solutions of tannic acid, nitrate of silver, or sulphide 
of zinc may be employed. The insufflation, two or three times a day, of a 
powder of iodoform, with morphia, after thoroughly cleansing the ulcers 
with a spray, relieves the pain in a majority of the cases. Cocaine (4-per- 
cent solution) applied with the atomizer will often enable the patient to 
swallow his food comfortably. There are, however, distressing cases of ex- 
tensive laryngeal and pharyngeal ulceration in which even cocaine loses its 
good effects. When the epiglottis is lost the difficulty in swallowing be- 
comes very great. Wolfenden states that this may be obviated if the pa- 
tient hangs his head over the side of the bed and sucks milk through a rub- 
ber tubing from a mug placed on the floor. 



VI. SYPHILITIC LARYNGITIS. 

Syphilis attacks the larynx with great frequency. It may result from 
the inherited disease or be a secondary or tertiary manifestation of the ac- 
quired form. 

Symptoms. — In secondary syphilis there is occasionally erythema of 
the larynx, which may go on to definite catarrh, but has nothing charac- 
teristic. The process may proceed to the formation of superficial whitish 
ulcers, usually symmetrically placed on the cords or ventricular bands. 
Mucous patches and condylomata are rarely seen. The symptoms are prac- 
tically those of slight loss of voice with laryngeal irritation, as in the simple 
catarrhal form. 

The tertiary laryngeal lesions are numerous and very serious. True 
gummata, varying in size from the head of a pin to a small nut, develop 
in the submucous tissue, most commonly at the base of the epiglottis. They 
go through the changes characteristic of these structures and may either 
break down, producing extensive and deep ulceration, or — and this is more 
characteristic of syphilitic laryngitis — in their healing form a fibrous tissue 
-which shrinks and produces stenosis. The ulceration is apt to extend 
deeply and involve the cartilage, inducing necrosis and exfoliation, and 
even haemorrhage from erosion of the arteries. (Edema may suddenly prove 
fatal. The cicatrices which follow the sclerosis of the gummata or the 
healing of the ulcers produce great deformity. The epiglottis, for instance, 
may be tied down to the pharyngeal wall or to the epiglottic folds, or even 
to the tongue; and eventually a stenosis results, which may necessitate 
tracheotomy. 

The laryngeal symptoms of inherited syphilis have the usual course of 
these lesions and appear either early, within the first five or six months, or 
after puberty; most commonly in the former period. Of 76 cases, J. N. 



ACUTE BRONCHITIS. 



621 



Mackenzie found that 63 occurred within the first year. The gummatous 
infiltration leads to ulceration, most commonly of the epiglottis and in the 
ventricles, and the process may extend deeply and involve the cartilage. 
Cicatricial contraction may also occur. 

The diagnosis of syphilis of the larynx is rarely difficult, since it occurs 
most commonly in connection with other symptoms of the disease. 

Treatment. — The administration of constitutional remedies is the 
most important, and under mercury and iodide of potassium the local symp- 
toms may rapidly he relieved. The tertiary laryngeal manifestations are 
always serious and difficult to treat. The deep ulceration is specially hard 
to combat, and the cicatrization may necessitate tracheotomy, or the gradual 
dilatation, as practised by Schroetter. 



III. DISEASES OF THE BRONCHI. 
I. ACUTE BRONCHITIS. 

Acute catarrhal inflammation of the bronchial mucous membrane is a 
very common disease, rarely serious in healthy adults, but very fatal in the 
old and in the young, owing to associated pulmonary complications. It is 
bilateral and affects either the larger and medium sized tubes or the smaller 
bronchi, in which case it is known as capillary bronchitis. 

We shall speak only of the former, as the latter is part and parcel of 
broncho-pneumonia. 

Etiology. — Acute bronchitis is a common sequel of catching cold, 
and is often nothing more than the extension downward of an ordinary 
coryza. It occurs most frequently in the changeable weather of early spring 
and late autumn. Its association with cold is well indicated by the popu- 
lar expression " cold on the chest/ 7 It may prevail as an epidemic apart 
from influenza, of which it is an important feature. 

Acute bronchitis is associated with many other affections, notably 
measles. It is by no means rare at the onset of typhoid fever and malaria. 
It is present also in asthma and whooping-cough. The subjects of spinal 
curvature are specially liable to the disease. The bronchitis of Bright's 
disease, gout, and heart-disease is usually a chronic form. It attacks per- 
sons of all ages, but most frequently the young and the old. There are in- 
dividuals who have a special disposition to bronchial catarrh, and the 
slightesl exposure is apt to bring on an attack. Persons who live an out- 
of-door life are usually less subject to the disease than those who follow 
sedentary occupations. 

The affection is probably microbic, though we have as yet no definite 
evidence upon this point. 

Morbid Anatomy. — The mncous membrane of the trachea and 
bronchi is reddened, congested, and covered with mucus and muco-pus, 
which may be seen oozing from the smaller bronchi, some of which are 
dilated. The finer changes in the mucosa consist in desquamation of the 



622 



DISEASES OF THE RESPIRATORY SYSTEM. 



ciliated epithelium, swelling and oedema of the submucosa, and infiltration 
of the tissue with leucocytes. The mucous glands are much swollen. 

Symptoms. — The symptoms of an ordinary " cold " accompany the 
onset of an acute bronchitis. The coryza extends to the tubes, and may 
also affect the larynx, producing hoarseness, which in many cases is marked. 
A chill is rare, but there is invariably a sense of oppression, with heavi- 
ness and languor and pains in the bones and back. In mild cases there is 
scarcely any fever, but in severer forms the range is from 101° to 103°. 
The bronchial symptoms set in with a feeling of tightness and rawness 
beneath the sternum and a sensation of oppression in the chest. The 
cough is rough at first, and often of a ringing character. It comes on in 
paroxysms which rack and distress the patient extremely. During the 
severe spells the pain may be very intense beneath the sternum and along 
the attachments of the diaphragm. At first the cough is dry and the ex- 
pectoration scanty and viscid, but in a few days the secretion becomes 
muco-purulent-and abundant, and finally purulent. With the loosening 
of the cough great relief is experienced. The sputum is made up largely 
of pus-cells, with a variable number of the large round alveolar cells, many 
of which contain carbon grains, while others have undergone the myelin 
degeneration. 

Physical Signs. — The respiratory movements are not greatly increased 
in frequency unless the fever is high. There are instances, however, in 
which the breathing is rapid and when the smaller tubes are involved 
there is dyspnoea. On palpation the bronchial fremitus may often be felt. 
On auscultation in the early stage, piping sibilant rales are everywhere to 
be heard. They are very changeable, and appear and disappear with cough- 
ing. With the relaxation of the bronchial membranes and the greater 
abundance of the secretion, the rales change and become mucous and bub- 
bling in quality. The bases of the lungs should be carefully examined 
each day, particularly in children and the aged. 

The course of the disease depends on the conditions under which it 
develops. In healthy adults, by the end of a week the fever subsides and 
the cough loosens. In another week or ten days convalescence is fully 
established. In young children the chief risk is in the extension of the 
process downward. In measles and whooping-cough, the ordinary bron- 
chial catarrh is very apt to descend to the finer tubes, which become dilated 
and plugged with muco-pus, inducing areas of collapse, and finally broncho- 
pneumonia. This extension is indicated by changes in the physical signs. 
Usually at the base the rales are subcrepitant and numerous and there 
may be areas of defective resonance and of feeble or distant tubular breath- 
ing. In the aged and debilitated there are similar dangers if the process 
extends from the larger to the smaller tubes. In old age the bronchial 
mucosa is less capable of expelling the mucus, which is more apt to sag to 
the dependent parts and induce dilatation of the tubes with extension of 
the inflammation to the contiguous air-cells. 

The diagnosis of acute bronchitis is rarely difficult. Although the 
mode of onset may be brusque and perhaps simulate pneumonia, yet the 
absence of dulness and blowing breathing, and the general character of 



CHRONIC BRONCHITIS, 



623 



the bronchial inflammation, render the diagnosis simple. About onee a 
year I see a case of typhoid fever, in which the diagnosis at first has been 
acute bronchitis. The complication of broncho-pneumonia is indicated by 
the greater severity of the symptoms, particularly the dyspnoea, the changed 
color, and the physical signs. 

Treatment. — In mild cases, household measures suffice. The hot 
foot-bath, or the warm bath, a drink of hot lemonade, and a mustard plaster 
on the chest will often give relief. For the dry, racking cough, the symp- 
tom most complained of by the patient, Dover's powder is the best remedy. 
It is a popular belief that quinine, in full doses, will check an oncoming 
cold on the chest, but this is doubtful. It is a common custom when per- 
sons feel the approach of a cold to take a Turkish bath, and though the 
tightness and oppression may be relieved by it, there is in a majority of the 
cases great risk. Some of the severest cases of bronchitis which I have 
seen have followed this initial Turkish bath. No doubt, if the person 
could go to bed directly from the bath, its action would be beneficial, but 
there is great risk of catching additional " cold " in going home from the 
bath. Belief is obtained from the unpleasant sense of rawness by keep- 
ing the air of the room saturated with moisture, and in this dry stage 
the old-fashioned mixture of the wines of antimony and ipecacuanha with 
liquor ammonii acetatis and nitrous ether is useful. If the pulse is very 
rapid, tincture of aconite may be given, particularly in the case of chil- 
dren. For the cough, when dry and irritating, opium should be freely 
used in the form of Dover's powder. Of course, in the very young and 
the aged care must be exercised in the use of opium, particularly if the 
secretions are free; but for the distressing, irritative cough, which keeps 
the patient awake, no remedy can take its place. As the cough loosens 
and the expectoration is more abundant, the patient becomes more com- 
fortable. In this stage it is customary to ply him with expectorants of 
various sorts. Though useful occasionally, they should not be given as a 
matter of routine. A mixture of squills, ammonia, and senega is a favorite 
one with many practitioners at this stage. 

In the acute bronchitis of children, if the amount of secretion is large 
and difficult to expectorate, or if there is dyspnoea and the color begins 
to get dusky, an emetic (a tablespoonful of ipecac wine) should be given 
at once and repeated if necessary. 



II. CHRONIC BRONCHITIS. 

Etiology. — This affection may follow repeated attacks of acute bron- 
chitis, but it is most commonly met with in chronic lung affections, heart- 
disease, aneurism of the aorta, gout, and renal disease. It is frequent in 
the aged; the young rarely are affected. Climate and season have an im- 
portant influence. It is the winter cough of the old man, which recurs 
with regularity as the weather gets cold and changeable. 

Morbid Anatomy. — The bronchial mucosa presents a great variety 
of changes, depending somewhat upon the disease with which chronic 
39 



624: 



DISEASES OF THE RESPIRATORY SYSTEM. 



bronchitis is associated. In some cases the mucous membrane is very 
thin, so that the longitudinal bands of elastic tissue stand out prominently. 
The tubes are dilated, the muscular and glandular tissues are atrophied, 
and the epithelium is in great part shed. 

In other instances the mucosa is thickened, granular, and infiltrated. 
There may be ulceration, particularly of the mucous follicles. Bronchial 
dilatations are not uncommon and emphysema is a constant accompani- 
ment. 

Symptoms. — In the form met with in old men, associated with em- 
physema, gout, or heart-disease, the chief symptoms are as follows: Short- 
ness of breath, which may not be noticeable except on exertion. The 
patients " puff and blow " on going up hill or up a flight of stairs. This is 
due not so much to the chronic bronchitis itself as to associated emphysema 
or even to cardiac weakness. They complain of no pain. The cough is 
variable, changing with the weather and with the season. During the 
summer they may remain free, but each succeeding winter the cough comes 
on with severity and persists. There may be only a spell in the morning, 
or the chief distress is at night. The sputum in chronic bronchitis is very 
variable. In cases of the so-called dry catarrh there is no expectoration. 
Usually, however, it is abundant, muco-purulent, or distinctly purulent in 
character. There are instances in which the patient coughs up for years 
a thin fluid sputum. There is rarely fever. The general health may be 
good and the disease may present no serious features apart from the lia- 
bility to induce emphysema and bronchiectasy. In many cases it is an 
incurable affection. Patients improve and the cough disappears in the 
summer time only to return during the winter months. 

Physical Signs. — The chest is usually distended, the movements are 
limited, and the condition is often that which we see in emphysema. The 
percussion note is clear or hyperresonant. On auscultation, expiration is 
prolonged and wheezy and rhonchi of various sorts are heard — some high- 
pitched and piping, others deep-toned and snoring. Crepitation is com- 
mon at the bases. 

Clinical Varieties. — The description just given is of the ordinary 
chronic bronchitis which occurs in connection with emphysema and heart- 
disease and in many elderly men. There are certain forms which merit 
special description: (a) On several occasions I have met with a form of 
chronic bronchitis, particularly in women, which comes on between the ages 
of twenty and thirty and may continue indefinitely without serious impair- 
ment of the health. 

(b) Bronchorrlma. — Excessive bronchial secretion is met with under 
several conditions. It must not be mistaken for the profuse expectoration 
of bronchiectasy. The secretion may be very liquid and watery — bronchor- 
rlma serosa, and in extraordinary amount. More commonly, it is purulent 
though thin, and with greenish or yellow-green masses. It may be thick 
and uniform. This profuse bronchial secretion is usually a manifestation 
of chronic bronchitis and may lead to dilatation of the tubes and ultimately 
to fetid bronchitis. In the young the condition may persist for years with- 
out impairment of health and without apparently damaging the lungs. 



CHRONIC BRONCHITIS. 



625 



(c) Putrid Bronchitis. — Fetid expectoration is met with in connection 
with bronchiectasis, gangrene, abscess, or with decomposition of secretions 
within phthisical cavities and in an empyema which has perforated the 
lung. There are instances in which, apart from any of these states, the 
expectoration has a fetid character. The sputa are abundant, usually 
thin, grayish-white in color, and they separate into an upper fluid layer 
capped with frothy mucus and a thick sediment in which may sometimes 
be found dirty yellow masses the size of peas or beans — the so-called Dit- 
tricri's plugs. The affection is very rare apart from the above-mentioned 
conditions. In severe cases it leads to changes in the bronchial walls, 
pneumonia, and often to abscess or gangrene. Metastatic brain abscess has 
followed putrid bronchitis in a certain number of cases. 

(d) Dry Catarrh. — The catarrhe sec of Laennec, a not uncommon form, 
is characterized by paroxysms of coughing of great intensity, with little or 
no expectoration. It is usually met with in elderly persons with emphy- 
sema, and is one of the most obstinate of all varieties of bronchitis. 

In England the damp cold of the unwarmed houses is responsible in 
great part for the prevalence of chronic bronchitis among, the aged and 
weak. An equable, warm temperature is of the first importance to all 
persons prone to the disease. 

Treatment. — By far the most satisfactory method of treating the 
recurring winter bronchitis is change of climate. Eemoval to a southern 
latitude may prevent the onset. Southern France, southern California, 
and Florida furnish winter climates in which the subjects of chronic bron- 
chitis live with the greatest comfort. All cases of prolonged bronchial 
irritation are benefited by change of air. 

The first endeavor in treating a case of chronic bronchitis is to ascer- 
tain, if possible, whether there are constitutional or local affections with 
which it is associated. In many instances the urine is found to be highly 
acid, perhaps slightly albuminous, and the arteries are stiff. In the form 
associated with this condition, sometimes called gouty bronchitis, the at- 
tacks seem related to the defective renal elimination, and to this condition 
the treatment should be first directed. In other instances there are heart- 
disease and emphysema. In the form occurring in old men much may be 
done in the way of prophylaxis. Septuagenarians should read Oliver Wen- 
dell Holmes's * " De Senectute " with reference to the care of the health. 
There is no doubt that with prudence even in our changeable winter 
weather much may be done to prevent the onset of chronic bronchitis. 
Woollen undergarments should be used and especial care should be taken 
in the spring months not to change them for lighter ones before the warm 
weather is established. 

Cure is seldom effected by medicinal remedies. There are instances 
in which iodide of potassium acts with remarkable benefit, and it should 
always be given a trial in cases of paroxysmal bronchitis of obscure origin. 
For the morning cough, bicarbonate of sodium (gr. xv), chloride of sodium 
(gr. v), spirits of chloroform (ttiv) in anise water and taken with an equal 



* Over the Tea-cups, Boston, 1890. 



G26 



DISEASES OF THE RESPIRATORY SYSTEM. 



amount of warm water will be found useful (Fowler). When there is much 
sense of tightness and fulness of the chest, the portable Turkish bath may 
be tried. When the secretion is excessive muriate of ammonia and senega 
are useful. Stimulating expectorants are contraindicated. When the heart 
is feeble, the combination of digitalis and strychnia is very beneficial. Tur- 
pentine, the old-fashioned remedy so warmly recommended by the Dublin 
physicians, has in many quarters fallen undeservedly into disuse. Prepara- 
tions of tar, creasote, and terebene are sometimes useful. Of other balsamic 
remedies, sandal-wood, the compound tincture of benzoin, copaiba, balsam 
of Peru or tolu may be used. Inhalations of eucalyptus and of the spray 
of ipecacuanha wine are often very useful. If fetor be present, carbolic 
acid in the form of spray (10 to 20 per cent solution) will lessen the odor, 
or thymol (1 to 1,000). For urgent dyspnoea with cyanosis, bleeding from 
the arm gives most relief. 



III. BRONCHIECTASIS. 

Etiology. — Dilatation of the bronchi occurs under the following con- 
ditions: (1) As a congenital defect or anomaly. Such cases are extremely 
rare, commonly unilateral. Grawitz has described the condition as bron- 
chiectasis universalis. Welch has met an instance in a young girl. (2) In 
connection with inflammation of the bronchi, particularly when this leads 
to weakness of the walls with the accumulation of secretion. I have seen 
an instance after influenza. Under this category comes the dilatation met 
with in chronic bronchitis and emphysema, the dilated bronchi in chronic 
phthisis, in the catarrhal pneumonias of children, and particularly the dila- 
tation which results from the presence of foreign bodies in the air-tubes 
or from pressure, as of an aneurism on one bronchus. (3) In extreme 
contraction of the lung tissue, whether due to interstitial pneumonia or to 
compression by pleural adhesions, bronchial dilatation is a common though 
not a constant accompaniment. 

Unquestionably the weakening of the bronchial wall is the most impor- 
tant, probably the essential, factor in inducing bronchiectasy, since the wall 
is then not able to resist the pressure of air in severe spells of coughing 
and in straining. In some instances the mere weight of the accumulated 
secretion may be sufficient to distend the terminal tubules, as is seen in 
compression of a bronchus by aneurism. 

Morbid Anatomy. — Two chief forms are recognized — the cylin- 
drical and the saccular — which may exist together in the same lung. The 
condition may be general or partial. Universal bronchiectasis is always 
unilateral. It occurs in rare congenital cases and is occasionally seen as a 
sequence of interstitial pneumonia. The entire bronchial tree is repre- 
sented by a series of sacculi opening one into the other. The walls are 
smooth and possibly without ulceration or erosion except in the dependent 
parts. The lining membrane of the sacculi is usually smooth and glisten- 
ing. The dilatations may form large cysts immediately beneath the pleura. 
Intervening between the sacculi is a dense cirrhotic lung tissue. The 



BRONCHIECTASIS. 



627 



partial dilatations — the saccular and cylindrical — are common in chronic 
phthisis, particularly at the apex, in chronic pleurisy at the base, and- in 
emphysema. Here the dilatation is more commonly cylindrical, some- 
times fusiform. The bronchial mucous membrane is much involved and 
sometimes there is a narrowing of the lumen. Occasionally one meets 
with a single saccular bronchiectasy in connection with chronic bronchitis 
or emphysema. Some of these look like simple cysts, with smooth walls, 
without fluid contents. A form of acute bronchiectasis in children has 
been described by Sharkey, Carr, and others. A good account of it is given 
in Fowler and Godlee's work on the lungs. 

Histologically the bronchi which are the seat of dilatation show im- 
portant changes. In the large, smooth dilatations the cylindrical is re- 
placed by a pavement epithelium. The muscular layer is stretched, atro- 
phied, and the fibres separated; the elastic tissue is also much stretched 
and separated. In the large saccular bronchiectases and in some of the 
cylindrical forms, due to retained secretions, the lining membrane is ulcer- 
ated. The contents of some of the larger bronchiectatic cavities are hor- 
ribly fetid. 

Symptoms. — In the limited dilatations of phthisis, emphysema, and 
chronic bronchitis, the symptoms are in great part those of the original 
disease, and the condition often is not suspected during life. 

In extensive saccular bronchiectasy the characters of the cough and 
expectoration are distinctive. The patient will pass the greater part of 
the day without any cough and then in a severe paroxysm will bring up 
a large quantity of sputum. Sometimes change of the position will bring 
on a violent attack, probably due to the fact that some of the secretion 
flows from the dilatation to a normal tube. The daily spell of coughing 
is usually in the morning. The expectoration is in many instances very 
characteristic. It is grayish or grayish brown in color, fluid, purulent, 
with a peculiar acid, sometimes fetid, odor. Placed in a conical glass, it 
separates into a thick granular layer below and a thin mucoid intervening 
layer above, which is capped by a brownish froth. Microscopically it 
consists of pus-corpuscles, often large crystals of fatty acids, which are 
sometimes in enormous numbers over the field and arranged in bunches. 
Hsematoidin crystals are sometimes present. Elastic fibres are seldom 
found except when there is ulceration of the bronchial walls. Tubercle 
bacilli are not present. In some cases the expectoration is very fetid 
and has all the characters of that described under fetid bronchitis. Num- 
mular expectoration, such as comes from phthisical cavities, is not com- 
mon. Haemorrhage occurred in 14 out of 35 cases analyzed by Fowler. 
Abscess of the brain has in a few instances followed the bronchiectasis. 
Rheumatoid affections may develop, and it is one of the conditions with 
which the pulmonary osteo-arthropathy is commonly associated. 

The diagnosis is not possible in a large number of the cases. In the 
extensive sacculated forms, unilateral and associated with interstitial pneu- 
monia or chronic pleurisy, the diagnosis is easy. There is contraction of 
the side, which in some instances is not at all extreme. The cavernous 
signs may be chiefly at the base and may vary according to the condi- 



628 



DISEASES OF THE RESPIRATORY SYSTEM. 



tion of the cavity, whether full or empty. There may be the most ex- 
quisite amphoric phenomena and loud resonant rales. The condition 
persists for years and is not inconsistent with a tolerably active life. The 
patients frequently show signs of marked embarrassment of the pul- 
monary circulation. There is cyanosis on exertion, the finger-tips are 
clubbed, and the nails incurved. A condition very difficult to distin- 
guish from bronchiectasy is a limited pleural cavity communicating with a 
bronchus. 

Treatment. — Medical treatment is not satisfactory, since it is impos- 
sible to heal the cavity. I have practised the injection of antiseptic fluids 
in some instances with benefit. Intratracheal injections have been very 
warmly recommended of late. With a suitable syringe a drachm may be 
injected twice a day of the following solution: Menthol 10 parts, guaia- 
col 2 parts, olive oil 88 parts. The creasote vapor bath may be given in a 
small room. The patient's eyes must be protected with well-fitting goggles, 
and the nostrils stuffed with cotton-wool. A drachm of creasote is poured 
upon water in a saucer and vaporized by placing the saucer over a spirit 
lamp. At first the vapor is very irritating and disagreeable, but the pa- 
tient gets used to it. The bath should be taken at first every other day 
for fifteen minutes, then gradually increased to an hour daily. The treat- 
ment should be continued for three months. I can recommend it as a 
most satisfactory method of treatment. In suitable cases drainage of the 
cavities may be attempted, particularly if the patient is in fairly good con- 
dition. For the fetid secretion turpentine may be given, or terebene, and 
inhalations used of carbolic acid or thymol. 



IV. BRONCHIAL ASTHMA. 

Asthma is a term which has been applied to various conditions ass©ci- 
ated with dyspnoea — hence the names cardiac and renal asthma — but its 
use should be limited to the affection known as bronchial or spasmodic 
asthma. 

Etiology. — All writers agree that there is in a majority of cases of 
bronchial asthma a strong neurotic element. Many regard it as a neu- 
rosis in which, according to one view, spasm of the bronchial muscles, ac- 
cording to the other turgescence of the mucosa, results from disturbed in- 
nervation, pneumogastric or vasomotor. Of the numerous theories the 
following are the most important: 

(1) That it is due to spasm of the bronchial muscles, a theory which 
has perhaps the largest number of adherents. The original experiments 
of C. J. B. Williams, upon which it is largely based, have not, however, 
been confirmed of late years. 

(2) That the attack is due to swelling of the bronchial mucous mem- 
brane — fluctionary hyperemia (Traube), vaso-motor turgescence (Weber), 
diffuse hyperasmic swelling (Clark). 

(3) That in many cases it is a special form of inflammation of the 
smaller bronchioles — bronchiolitis exudativa (Curschmann). Other theo- 



BRONCHIAL ASTHMA. 



629 



ries which may be mentioned are that the attack depends on spasm of the 
diaphragm or on reflex spasm of all the inspiratory muscles. 

As already mentioned, the so-called hay fever is an affection which has 
many resemblances to bronchial asthma, with which the attacks may alter- 
nate. In the suddenness of onset and in many of their features these dis- 
eases have the same origin and differ only in site, as suggested by Sir 
Andrew Clark and now generally acknowledged by specialists. Making- 
due allowance for anatomical differences, if the structural changes occur- 
ring in the nasal mucous membrane during an attack of hay fever were to 
occur also in various parts of the bronchial mucosa, their presence there 
would afford a complete and adequate explanation of the facts observed 
during a paroxysm of bronchial asthma (Clark). With this statement I 
fully agree, but the observations of Curschmann have directed attention 
to a feature in asthma which has been neglected; namely, that in a ma- 
jority of the cases it is associated with an exudation, such as might be 
supposed to come from a turgescent mucosa and which is of a very charac- 
teristic and peculiar character. The hyperemia and swelling of the mu- 
cosa and the extremely viscid, tenacious mucus explain well the hindrance 
to inspiration and expiration and also the quality of the rales. An oedema 
of the angio-neurotic type has been described in the hands and arms in 
asthma (J. S. Billings, Jr.). 

Some general facts with reference to etiology may be mentioned. The 
affection sometimes runs in families, particularly those with irritable and 
unstable nervous systems. The attack may be associated with neuralgia 
or, as Salter mentions, even alternate with epilepsy. Men are more fre- 
quently affected than women. The disease often begins in childhood and 
sometimes lasts until old age. It may follow an attack of whooping-cough. 
One of its most striking peculiarities is the bizarre and extraordinary variety 
of circumstances which at times induce a paroxysm. Among these local 
conditions climate or atmosphere are most important. A person may be 
free in the city and invariably suffer from an attack when he goes into the 
country, or into one special part of the country. Such eases are by no 
means uncommon. Breathing the air of a particular room or a dusty at- 
mosphere may bring on an attack. Odors, particularly of flowers and of 
hay, or emanations from animals, as the horse, dog, or cat, may at once cause 
an outbreak. Fright or violent emotion of any sort may bring on a parox- 
ysm. Uterine and ovarian troubles were formerly thought to induce at- 
tacks and may do so in rare instances. Diet, too, has an important influ- 
ence, and in persons subject to the disease severe paroxysms may be induced 
by overloading the stomach, or by taking certain articles of food. Chronic 
cases, in which the attacks recur year after year, gradually become asso- 
ciated with emphysema, and every fresh " cold " induces a paroxysm. And 
lastly, many cases of bronchial asthma are associated with affections of the 
nose, particularly with hypertrophic rhinitis and nasal polypi. According 
to some specialists of large experience, all cases of bronchial asthma have 
some affection of the upper air-passages, but I am convinced from personal 
observation that this is erroneous. Still physicians must acknowledge the 
debt which we owe to Yoltolini, Hack, Daly, Hoe, and others who have 



630 



DISEASES OF THE RESPIRATORY SYSTEM. 



shown the close connection which exists between affections of the naso- 
pharynx and many cases of bronchial asthma. 

Briefly stated then, bronchial asthma is a neurotic affection, character- 
ized- by hyperemia and turgescence of the mucosa of the smaller bronchial 
tubes and a peculiar exudate of mucin. The attacks may be due to direct 
irritation of the bronchial mucosa or may be induced reflexly, by irritation 
of the nasal mucosa, and indirectly, too, by reflex influences, from stomach, 
intestines, or genital organs. 

Symptoms. — Premonitory sensations precede some attacks, such as 
chilly feelings, a sense of tightness in the chest, flatulence, the passage of a 
large quantity of urine, or great depression of spirits. Nocturnal attacks 
are common. After a few hours' sleep, the patient is aroused with a dis- 
tressing sense of want of breath and a feeling of great oppression in the 
chest. Soon the respiratory efforts become violent, all the accessory mus- 
cles are brought into play, and in a few minutes the patient is in a paroxysm 
of the most intense dyspnoea. The face is pale, the expression anxious, 
s'peech is impossible, and in spite of the most strenuous inspiratory efforts 
very little air enters the lungs. Expiration is prolonged and also wheezy. 
The number of respirations, however, is not much increased. The asth- 
matic fit may last from a few minutes to several hours. When severe, the 
signs of defective aeration soon appear, the face becomes bedewed with 
sweat, the pulse is small and quick, the extremities get cold, and just as 
the patient seems to be at his worst, the breathing begins to get easier, and 
often with a paroxysm of coughing relief is obtained and he sinks ex- 
hausted to sleep. The relief may be but temporary and a second attack 
may soon come on. In a majority of the cases even in the intervals be- 
tween the asthmatic fits the respiration is somewhat embarrassed. The 
cough is at first very tight and dry and the expectoration is tenacious. Em- 
physema of the neck may occur during the violent coughing spells. 

The physical signs during an attack are very characteristic. On in- 
spection the thorax looks enlarged, barrel-shaped, and is fixed, the amount 
of expansion being altogether disproportionate to the intensity of the in- 
spiratory movements. The diaphragm is lowered and moves but slightly. 
Inspiration is short and quick, expiration prolonged. Percussion may not 
reveal any special difference, but there is sometimes marked hyperreso- 
nance, particularly in cases which have had repeated attacks. 

On auscultation, with inspiration and expiration, there are innumer- 
able sibilant and sonorous rales of all varieties, piping and high-pitched, 
low-pitched and grave. Later in the attack there are moist rales. 

The sputum in bronchial asthma is quite distinctive, unlike that which 
occurs in any other affection. Early' in the attack it is brought up with 
great difficulty and is in the form of rounded gelatinous masses, the so- 
called " perles " of Laennec. Though ball-like, they can be unfolded and 
really represent moulds in mucus of the smaller tubes. The entire expec- 
toration may be made up of these somewhat translucent-looking pellets, 
floating in a small quantity of thin mucus. Some of them are opaque. 
Often with a naked eye a twisted spiral character can be seen, particularly 
if the sputum is spread on a glass with a black background. Microscopic- 



BRONCHIAL ASTHMA. 



631 



ally, many of these pellets have a spiral structure, which renders them 
among the most remarkable bodies met with in sputum. It is not a little 
curious that they should have been practically overlooked until described a 
few years ago by Curschmann. Under the microscope the spirals are of 
two forms. In one there is simply a twisted, spirally arranged mucin, in 
which are entangled leucocytes, the majority of which are eosinophiles. 
The twist may be loose or tight. The second form is much more peculiar. 
In the centre of a tightly coiled skein of mucin fibrils with a few scattered 
cells is a filament of extraordinary clearness and translucency, probably 
composed of transformed mucin. As Curschmann suggests, these spirals 
are doubtless formed in the finer bronchioles and constitute the product 
of an acute bronchiolitis. It is difficult to explain their spiral nature. I 
do not know of any observations upon the course of the currents produced 
by the ciliated epithelium in the bronchi, but it is quite possible that their 
action may be rotator}^ in which case, particularly when combined with 
spasm of the bronchial muscles, it is possible to conceive that the mucus 
formed in the tube might be compelled to assume a spiral form. Within 
two or three days the sputum changes entirely in character; it becomes 
muco-purulent and Curschmann's spirals are no longer to be found. They 
occur in all instances of true bronchial asthma in the early period of the 
attack. I have never seen the true spirals either in bronchitis or pneu- 
monia. There are, in addition, in many cases, the pointed, octahedral crys- 
tals described by Leyden and sometimes called asthma crystals. They are 
identical with the crystals found in the semen and in the blood in leu- 
kaemia. At one time they were supposed, by their irritating character, to 
induce the paroxysms. Eosinophiles in the blood are enormously increased 
in asthma — to 25 or 35 per cent of the leucocytes, or even to 53.6 per cent 
in one case (J. S. Billings, Jr.). 

The course of the disease is very variable. In severe attacks the par- 
oxysms recur for three or four nights or even more, and in the intervals 
and during the day there may be wheezing and cough. Early in the disease 
the patient may be free in the morning, without cough or much distress, 
and the attacks may appear at first to be of a purely nervous character. In 
the long-standing cases emphysema almost invariably develops, and while 
the pure asthmatic fits diminish in frequency the chronic bronchitis and 
shortness of breath become aggravated. 

We have no knowledge of the morbid anatomy of true asthma. Death 
during the attack is unknown. In long-standing cases the lesions are those 
of chronic bronchitis and emphysema. 

Treatment. — The asthmatic attack usually demands immediate and 
prompt treatment, and remedies should be administered which experience 
has shown are capable of relieving the condition of the bronchial mucosa. 
A few whiffs of chloroform will produce prompt though temporary relaxa- 
tion. In a child with very severe attacks, resisting all the usual remedies, 
the treatment by chloroform gave immediate and finally permanent relief. 
Hypodermic injections of pilocarpin (gr. J) will sometimes relax the mu- 
cosa in the profuse sweating. Perles of nitrite of amy] may be broken 
on the handkerchief or from two to five drops of the solution may be placed 



632 



DISEASES OF THE RESPIRATORY SYSTEM. 



■upon cotton-wool and inhaled. Strong stimulants given hot or a dose of 
spirits of chloroform in hot whisky will sometimes induce relaxation. More 
permanent relief is given by the hypodermic injection of morphia or of 
morphia and cocaine combined. In obstinate and repeatedly recurring 
attacks this has proved a very satisfactory plan. The sedative antispas- 
modics, such as belladonna, henbane, stramonium, and lobelia, may be 
given in solution or used in the form of cigarettes. Nearly all the popular 
remedies either in this form or in pastilles contain some plant of the order 
solanacece, with nitrate or chlorate of potash. Excellent cigarettes are now 
manufactured and asthmatics try various sorts, since one form benefits one 
patient, another form another patient. Nitre paper made with a strong 
solution of nitrate of potash is very serviceable. Filling the room with the 
fumes of this paper prior to retiring will sometimes ward off a nocturnal 
attack. I have known several patients to whom tobacco smoke inhaled was 
quite as potent as the prepared cigarettes. 

The use of compressed air in the pneumatic cabinet is very beneficial; 
oxygen inhalations may also be tried. In preventing the recurrence of 
the attacks there is no remedy so useful as iodide of potassium, which some- 
times acts like a specific. From 10 to 20 grains three times a day is usu- 
ally sufficient. 

Particular attention should be paid to the diet of asthmatic patients. 
A rule which experience generally compels them to make is to take the 
heavy meals in the early part of the day and not retire to bed before gas- 
trie digestion is completed. As the attacks are often induced by flatu- 
lency, the carbohydrates should be restricted. Coffee is a more suitable 
drink than tea. In respect to climate it is very difficult to lay down rules 
for asthmatics. The patients are often much better in the city than in 
the country. The high and dry altitudes are certainly more beneficial than 
the sea-shore; but in protracted cases, with emphysema as a secondary com- 
plication, the rarefied air of high altitudes is not advantageous. In young 
persons I have known a residence for six months in Florida or southern 
California to be followed by prolonged freedom from attacks. 



V. FIBRINOUS BRONCHITIS. 

Definition. — An acute or chronic affection, characterized by the for- 
mation in certain of the bronchial tubes of fibrinous casts, which are ex- 
pelled in paroxysms of dyspnoea and cough. 

In several diseases fibrinous moulds of the bronchi are formed, as in 
diphtheria (with extension into the trachea and bronchi), in pneumonia, 
and occasionally in phthisis — conditions which, however, have nothing to 
do with true fibrinous bronchitis. These casts are not to be confounded 
with the blood-casts which occur occasionally in haemoptysis. 

Clinical Description. — Bettman, in reporting a case which occurred 
in Prof. Whitridge Williams's obstetrical clinic at the Johns Hopkins Hos- 
pital, has analyzed all the cases from the literature since 1869, grouping 
them into different classes. The first and most important is chronic idi- 



FIBRINOUS BRONCHITIS. 



633 



opatliic fibrinous bronchitis. It is a rare affection. I have met with only 
3 cases. Of 27 cases, 15 were in males. It is most common at the middle 
period of life. The attacks may occur at definite intervals for months or 
years. The form and size of the casts may he identical at each attack as 
though each time precisely the same bronchial area was involved. The 
expectoration of the casts is associated with paroxysms of dyspnoea and 
coughing, which occur at longer or shorter intervals. Fever and haemop- 
tysis may be present during the attack. Physical signs usually indicate 
the portion of the lung affected, as there are suppressed breath sounds and 
numerous rales on coughing. A very dry rale, called the "bruit de dra- 
peau," has been described, caused by the vibration of a loosened portion 
of the cast. 

In five cases there were skin lesions. Tuberculosis is sometimes pres- 
ent. Death occurred in only one case of the series. The casts are usually 
rolled up and mixed with mucus and blood. When unrolled they are large 
white branching structures. The main stem may be as thick as the little 
finger. From the consistency and appearance they have been described 
as fibrinous, but they consist mainly of mucin. On cross-section they show 
a concentrically stratified structure, with leucocytes and alveolar epithe- 
lium. Leyden's crystals and Curschmann's spirals are sometimes found, 
and in Bettman's case there were protozoan-like bodies. 

There is a very remarkable acute form, of which Bettman has col- 
lected 15 cases. It comes on most frequently during some fever, as typhoid, 
pneumonia, or the eruptive fevers. After a preliminary bronchitis the 
dyspnoea increases, and then the casts are coughed up. Chills and fever 
have been present. Four of the 15 cases proved fatal, and the casts were 
found in situ. It is much more serious than the chronic form. There may 
be casts expectorated which have not the arborescent structure of the true 
fibrinous moulds, but which come from a single tube or its bifurcation. 
Sometimes they are very small and " tail off " into true Curschmann's 
spirals. I had two interesting cases of this sort during the session of 
1900- ? 01, both in connection with chronic bronchitis. Fibrinous casts 
are expectorated in connection with chronic heart disease (10 cases) and in 
pulmonary tuberculosis (14 cases), in the latter disease usually late in the 
course and of unfavorable omen. In the albuminous expectoration follow- 
ing tapping of a pleural exudate fibrinous casts have been coughed up. 

In haemoptysis blood-casts may be expectorated, and they are not to be 
confounded with the casts of true fibrinous bronchitis which may be 
coughed up in an attack of haemoptysis. 

In pneumonia small fibrinous plugs are not uncommon in the sputa, 
and in a few rare instances quite large moulds of the tubes may be 
coughed up. 

The mycelium of the aspergillus fumigatus may form membranous casts 
in the bronchi. I reported an instance of the kind in which a small partial 
mould of this kind was expectorated, and there is on record a case in which 
for long periods membranes composed of this fungus were coughed up in 
attacks of dyspnoea. 

The pathology of the disease is obscure. The membrane is identical 
with that to which the term croupous is applied, and the obscurity relates 



634 



DISEASES OF THE RESPIRATORY SYSTEM. 



not so much to the mechanism of the production, which is probably the 
same as in other mucous surfaces, as to the curious limitation of the affec- 
tion to certain bronchial territories and in the chronic form the remark- 
able recurrence at stated or irregular intervals throughout a period of many 
years. 

In the fatal cases the bronchial mucous membrane may be found in- 
jected or pale. In Biermer's case the epithelial lining was intact beneath 
the cast, but in that of Kretschy the bronchi were denuded of their epi- 
thelium. Emphysema is almost invariably present. Evidences of recent 
or antecedent pleurisy are sometimes found. Model, in an article published 
from Baumler's clinic, states that tuberculosis was present in 10 out of 
21 autopsies. 

In the acute cases the treatment should be that of ordinary acute bron- 
chitis. We know of nothing which can prevent the recurrence of the at- 
tacks in the chronic form. In the uncomplicated cases there is rarely any 
danger during the paroxysm, even though the symptoms may be most dis- 
tressing and the dyspnoea and cough very severe. Inhalations of ether, 
steam^ or atomized lime-water aid in the separation of the membranes. 
Waldenberg employed the last remedy with success in one case. Ewart 
recommends intratracheal injections of olive oil. Pilocarpine might be 
useful, as in some instances it increases the bronchial secretion. The em- 
ployment of emetics may be necessary, and in some cases they are effective 
in promoting the removal of the casts. 

IY. DISEASES OF THE LUNGS. 

I. CIRCULATORY DISTURBANCES IN THE LUNGS. 

Congestion.; — There are two forms of congestion of the lungs — active and 
passive. 

(1) Active Congestion of the Lungs. — Much doubt and confusion still 
exist on this subject. French writers, following Woillez, regard it as an 
independent primary affection (maladve de Woillez), and in their diction- 
aries and text-books allot much space to it. English and American au- 
thors more correctly regard it as a symptomatic affection. Active fluxion 
to the lungs occurs with increased action of the heart, and when very hot 
air or irritating substances are inhaled. In diseases which interfere locally 
with the circulation the capillaries in the adjacent unaffected portions may 
be greatly distended. The importance, however, of this collateral fluxion, 
as it is called, is probably exaggerated. In a whole series of pulmonary affec- 
tions there is this associated congestion — in pneumonia, bronchitis, pleu- 
risy, and tuberculosis. 

The symptoms of active congestion of the lungs are by no means defi- 
nite. The description given by Woillez and by other French writers is of 
an affection which is difficult to recognize from anomalous or larval forms 
of pneumonia. The chief symptoms described are initial chill, pain in the 
side, dyspnoea, moderate cough, and temperature from 101° to 103°. The 
physical signs are defective resonance, feeble breathing, sometimes bronchial 



CIRCULATORY DISTURBANCES IN THE LUNGS. 



635 



in character, and fine rales. A majority of clinical physicians would un- 
doubtedly class such cases under inflammation of the lung. In many epi- 
demics the abnormal and larval forms are specially prevalent. This is no 
doubt the condition to which Porcher, of Charleston, called attention a short 
time ago as a " hitherto undescribed affection of the lungs." 

The occurrence of an intense and rapidly fatal congestion of the lung, 
following extreme heat or cold or sometimes violent exertion, is recognized 
by some authors. Kenforth, the oarsman, is said to have died from this 
cause during the race at Halifax. Leuf has described cases in which, in 
association with drunkenness, exposure, and cold, death occurred suddenly, 
or within twenty-four hours, the only lesion found being an extreme, almost 
hemorrhagic, congestion of the lungs. It is by no means certain that in 
these cases death really occurs from pulmonary congestion in the absence 
of specific statements with reference to the coronary arteries. Several 
times in sudden death from disease of these vessels I have seen great en- 
gorgement of the lungs though not the extreme grade mentioned by Leuf. 
I have no personal knowledge of cases such as he describes. 

(2) Passive Congestion. — Two forms of this may be recognized, the me- 
chanical and the hypostatic. 

(a) Mechanical congestion occurs whenever there is an obstacle to the 
return of the blood to the heart. It is a common event in many affections 
of the left heart. The lungs are voluminous, russet brown in color, cut- 
ting and tearing with great resistance. On section they show at first a 
brownish-red tinge, and then the cut surface, exposed to the air, becomes 
rapidly of a vivid red color from oxidation of the abundant haemoglobin. 
This is the condition known as brown induration of the lung. Histologic- 
ally it is characterized by (a) great distention of the alveolar capillaries; 
(/8) increase in the connective-tissue elements of the lung; (y) the pres- 
ence in the alveolar walls of many cells containing altered blood-pigment; 
(8) in the alveoli numerous epithelial cells containing blood-pigment in all 
stages of alteration, which are also found in great numbers in the sputum. 

It occasionally happens that this mechanical hyperemia of the lung 
results from pressure by tumors. So long as compensation is maintained 
the mechanical congestion of the lung in heart-disease does not produce any 
symptoms, but with enfeebled heart action the engorgement becomes marked 
and there are dyspnoea, cough, and expectoration, with the characteristic 
alveolar cells. 

(b) Hypostatic congestion. In fevers and adynamic states generally, it 
is very common to find the bases of the lungs deeply congested, a condition 
induced partly by the effect of gravity, the patient lying recumbent in one 
posture for a long time, but chiefly by weakened heart action. That it is 
not an effect of gravity alone is shown by the fact that a healthy person 
may remain in bed an indefinite time without its occurrence. The term 
hypostatic congestion is applied to it. The posterior parts of the lung are 
dark in color and engorged with blood and scrum; in some instances to 
such a degree that the alveoli no longer contain air and portions of the lung 
sink in water. The term splenization and hypostatic pneumonia have been 
given to these advanced grades. It is a common affection in protracted 



636 



DISEASES OF THE RESPIRATORY SYSTEM. 



cases of typhoid fever and in long debilitating illnesses. In ascites, meteor- 
ism, and abdominal tumors the bases of the lungs may be compressed and 
congested. In this connection must be mentioned the form of passive con- 
gestion met with in injury to, and organic disease of, the brain. In cere- 
bral apoplexy the bases of the lungs are deeply engorged, not quite airless, 
but heavy, and on section drip with blood and serum. I have twice seen 
this condition in an extreme grade throughout the lungs in death from mor- 
phia poisoning. In some instances the lung tissue has a blackish, gelati- 
nous, infiltrated appearance, almost like diffuse pulmonary apoplexy. Occa- 
sionally this congestion is most marked in, and even confined to, the 
hemiplegic side. In prolonged coma the hypostatic congestion may be 
associated with patches of consolidation, due to the aspiration of portions 
of food into the air-passages. 

The symptoms of hypostatic congestion are not at all characteristic, 
and the condition has to be sought for by careful examination of the bases 
of the lungs, when slight dulness, feeble, sometimes blowing, breathing and 
liquid rales can be detected. 

The treatment of congestion of the lungs is usually that of the condi- 
tion with which it is associated. In the intense pulmonary engorgement, 
which may possibly occur primarily, and which is met with in heart-disease 
and emphysema, free bleeding should be practised. From 20 to 30 ounces 
of blood should be taken from the arm, and if the blood does not flow 
freely and the condition of the patient is desperate, aspiration of the right 
auricle may be performed. 

(Edema. — In all forms of intense congestion of the lungs there is a 
transudation of serum from the engorged capillaries chiefly into the air- 
cells, but also into the alveolar walls. Not only is it very frequent in con- 
gestion, but also with inflammation, with new growths, infarcts, and tuber- 
cles. When limited to the neighborhood of an affected part, the name 
collateral oedema is sometimes applied to it. General oedema occurs under 
conditions very similar to those met with in congestion. It is very often, 
no doubt, a terminal event, occurring with the death agony. It is seen in 
typical form in the cachexias, in death from anaemia, also in chronic Bright's 
disease, disease of the heart, and cerebral affections. 

The oedematous lung is heavy, looks watery, pits on pressure, and from 
the cut surface a large quantity of clear and, in cases of congestion, bloody 
serum flows freely; the tissue may even have a gelatinous, infiltrated ap- 
pearance. The condition is much more common at the bases, but it may 
exist throughout the entire lung. The pathology of pulmonary oedema is 
not always clear. Two factors usually prevail in extreme cases — increased 
tension within the pulmonary system and a diluted blood plasma. The 
increased tension alone is not capable of producing it. The experiments 
of Welch seem to indicate that the essential factor lies in a disproportion- 
ate weakness of the left ventricle, so that the blood accumulates in the 
lung capillaries until transudation occurs, a view which satisfactorily ex- 
plains certain cases, particularly the terminal cedemas. 

The symptoms of oedema of the lungs are often only an aggravation of 
those already existing, and are clue to the primary disease, whether car- 



CIRCULATORY DISTURBANCES IN THE LUNGS. 637 

diac, renal, or general. There are usually increasing dyspnoea and cough, 
and on examination there may be defective resonance and large liquid rales 
at the bases. There are cases in which the oedema comes on with great 
suddenness, and in chronic Bright's disease it may prove rapidly fatal. 

In the cases of so-called inflammatory oedema fever is always present, 
and there are often signs, more or less marked, of pneumonia. 

The treatment of oedema of the lung is practically that of the condi- 
tions with which it is associated. In the acute cases active catharsis, and, 
if there is cyanosis, free venesection should be resorted to. 

Pulmonary Hemorrhage. — This occurs in two forms — 'broncho-pul- 
monary hemorrhage, sometimes called bronchorrhagia, in which the blood 
is poured out into the bronchi and is expectorated, and pulmonary apo- 
plexy or pneumorrhagia, in which the haemorrhage takes place into the 
air-cells and the lung tissue. 

1. Broncho-pulmonary Hemorrhage; Hemoptysis. — Spitting of blood, 
to which the term haemoptysis should be restricted, results from a variety 
of conditions, among which the following are the most important: (a) In 
young healthy persons haemoptysis may occur without warning, and after 
continuing for a few days disappear and leave no ill traces. There may 
be at the time of the attack no physical signs indicating pulmonary disease. 
In such cases good health may be preserved for years and no further 
trouble occur. These cases are not very uncommon. In Ware's impor- 
tant contribution to this subject,* of 386 cases of haemoptysis noted in 
private practice 62 recovered and pulmonary disease did not subsequently 
develop in them. I know three professional men who had haemoptysis as 
students, and who now, at periods of from fifteen to eighteen years subse- 
quently, remain in perfect health, (b) Haemoptysis in pulmonary tubercu- 
losis, which is considered in pages 3*02-304. (c) In connection with cer- 
tain diseases of the lung, as pneumonia (in the initial stage) and cancer, 
occasionally in gangrene, abscess, and bronchiectasis, haemoptysis occurs. 
(d) Haemoptysis is met with in many heart affections, particularly mitral 
lesions. It may be profuse and recur at intervals for years, (e) In ulcera- 
tive affections of the larynx, trachea, or bronchi. Sometimes the haemor- 
rhage is profuse and rapidly fatal, as when an ulcer erodes a large branch 
of the pulmonary artery, an accident which I have known to happen in 
a case of chronic bronchitis with emphysema, (f) Aneurism is an occa- 
sional cause of haemoptysis. It may be sudden and rapidly fatal when the 
sac bursts into the air-passages. Slight bleeding may continue for weeks or 
even longer, due to pressure on the mucous membrane or erosion of the lung; 
or in some cases the sac " weeps " through the exposed laminae of fibrin. 
(g) Vicarious haemorrhage, which occurs in rare instances in cases of inter- 
rupted menstruation. The instances are well authenticated. Flint men- 
tions a case which he had had under observation for four years, and Hip- 
pocrates refers to it in the aphorism, " Haemoptysis in a woman is removed 
by an eruption of the menses." Periodical haemoptysis has also been met 
with after the removal of both ovaries. Even fatal haemorrhage has oc- 



* On Ilamioptysis as a Symptom, by John Ware, M.D. 



638'* 



DISEASES OF THE RESPIRATORY SYSTEM. 



eurred from the lung during menstruation when no lesion was found to 
aeount for it. (h) There is a form of recurring haemoptysis in arthritic 
subjects to which Sir Andrew Clark has called special attention and which 
also is described by French writers. The cases occur in persons over fifty 
years of age who usually present signs of the arthritic diathesis. It rarely 
leads to fatal issue and subsides without inducing pulmonary changes, (i) 
Haemoptysis recurs sometimes in malignant fevers and in purpura hemor- 
rhagica. Lastly, there is endemic haemoptysis, due to the Distomum ivester- 
manni in the bronchial tubes, an affection which is confined to parts of 
China and Japan. 

Symptoms. — Haemoptysis sets in as a rule suddenly. Often with- 
out warning the patient experiences a warm, saltish taste as the mouth 
fills with blood. Coughing is usually induced. There may be only an 
ounce or so brought up before the haemorrhage stops, or the bleeding may 
continue for days, the patient bringing up small quantities. In other in- 
stances, particularly when a large vessel is eroded or an aneurism bursts, 
the amount is large, and the patient after a few attempts at coughing shows 
signs of suffocation and death is produced by inundation of the bronchial 
system. Fatal haemorrhage may even occur into a large cavity in a patient 
debilitated by phthisis without the production of haemoptysis. I dissected 
a case of this kind at the Philadelphia Hospital. The blood from the lungs 
generally has characters which render it readily distinguishable from the 
blood which is vomited. It is alkaline in reaction, frothy, and mixed with 
mucus, and when coagulation occurs air-bubbles are present in the clot. 
Blood-moulds of the smaller bronchi are sometimes seen. Patients can 
usually tell whether the blood has been brought up by coughing or by 
vomiting, and in a majority of cases the history gives important indica- 
tions. In paroxysmal haemoptysis connected with menstrual disturbances 
the practitioner should see that the blood is actually coughed up, since de- 
ception may be practised. The spurious haemoptysis of hysteria is consid- 
ered with that disease. Naturally, the patient is at first alarmed at the 
occurrence of bleeding, but, unless very profuse, as when due to rupture 
of an aortic aneurism in a pulmonary cavity, the danger is rarely immedi- 
ate. The attacks, however, are apt to recur for a few days and the sputa 
may remain blood-tinged for a longer period. In the great majority of 
cases the haemorrhage ceases spontaneously. It should be remembered 
that some of the blood may be swallowed and produce vomiting, and, 
after a day or two, the stools may be dark in color. It is not well during 
an attack of haemoptysis to examine the chest. It was formerly thought 
that haemorrhage exercised a prejudicial effect and excited inflammation 
of the lungs, but this is not often the case. 

(2) Pulmonary Apoplexy; Hemorrhagic Infarct. — In this condition 
the blood is effused into the air-cells and interstitial tissue. It is rarely 
indeed diffuse, the parenchyma being broken, as is the brain tissue in 
cerebral apoplexy. Sometimes, in disease of the brain, in septic condi- 
tions, and in the malignant forms of fevers, the lung tissue is uniformly 
infiltrated with blood and has, on section, a black, gelatinous appearance. 

As a rule, the haemorrhage is limited and results from the blocking of 



CIRCULATORY DISTURBANCES IN THE LUNGS. 



639 



a branch of the pulmonary artery either by a thrombus or an embolus. 
The condition is most common in chronic heart-disease. Although the 
pulmonary arteries are terminal ones, blocking is not always followed by 
infarction; partly because the wide capillaries furnish sufficient anasto- 
mosis, and partly because the bronchial vessels may keep up the circula- 
tion. The infarctions are chiefly at the periphery of the lung, usually 
wedge-shaped, with the base of the wedge toward the surface. When re- 
cent, they are dark in color, hard and firm, and look on section like an 
•ordinary blood-clot. Gradual changes go on, and the color becomes a 
reddish brown. The pleura over an infarct is usually inflamed. A mi- 
croscopical section shows the air-cells to be distended with red blood-cor- 
puscles, which may also be in the alveolar walls. The infarcts are usually 
multiple and vary in size from a walnut to an orange. Very large ones 
may involve the greater part of a lobe. In the artery passing to the 
.affected territory a thrombus or an embolus is found. The globular 
thrombi, formed in the right auricular appendix, play an important part 
in the production of hemorrhagic infarction. In many cases the source 
of the embolus cannot be discovered, and the infarct may have resulted 
from thrombosis in the pulmonary artery, but, as before mentioned, it is 
not infrequent to find total obstruction of a large branch of a pulmonary 
artery without haemorrhage into the corresponding lung area. The fur- 
ther history of an infarction is variable. It is possible that in some in- 
stances the circulation is re-established and the blood removed. More 
commonly, if the patient lives, the usual changes go on in the extravasated 
blood and ultimately a pigmented, puckered, fibroid patch results. Slough- 
ing may occur with the formation of a cavity. Occasionally gangrene 
results. In a case at the University Hospital, Philadelphia, a gangrenous 
infarct ruptured and produced fatal pneumothorax. 

The symptoms of pulmonary apoplexy are by no means definite. The 
■condition may be suspected in chronic heart-disease when haemoptysis 
occurs, particularly in mitral stenosis, but the bleeding may be due to the 
•extreme engorgement. When the infarcts are very large, and particularly 
in the lower lobe, in which they most commonly occur, there may be signs 
of consolidation with blowing breathing. 

Treatment of Pulmonary Haemorrhage. — The pressure with- 
in the pulmonary artery is considerably less than that in the aortic system. 
The system is under vaso-motor control, but our knowledge of the mutual 
relations of pressure in the aorta and in the pulmonary artery, under vary- 
ing conditions, is still very imperfect (Bradford). There may be an influ- 
ence on the systemic blood-pressure without any on the pulmonary, and the 
pressure in the one may rise while it falls in the other, or it may rise and 
fall in both together. The researches of Brodie and Dixon indicate that 
drugs which raise the peripheral blood-pressure by vasoconstriction in- 
crease the total blood in the lung. In Andrew's Ilarveian Oration these 
relations are thoroughly described, and a statement is made, based on Brad- 
ford's experiments, as to the action on the pulmonary blood-pressure of 
many of the drugs employed in haemoptysis. Thus ergot, the remedy 
40 



DISEASES OF THE RESPIRATORY SYSTEM. 



perhaps most commonly used, causes a distinct rise in the pulmonary 
blood-pressure, while aconite produces a definite fall. 

The anatomical condition in haemoptysis is either hyperemia of the 
bronchial mucosa (or of the lung tissue) or a perforated vessel. In the 
latter case the patient often passes rapidly beyond treatment, though there- 
are instances of the most profuse haemorrhage, which must have come from 
a perforated artery or a ruptured aneurism, in which recovery has occurred. 
Practically, for treatment, we should separate these cases, as the remedies, 
which would be applicable in a case of congested and bleeding mucosa 
would be as much out of place in a case of haemorrhage from ruptured 
aneurism as in a cut radial artery. When the blood is brought up in large 
quantities, it is almost certain either that an aneurism has ruptured or a 
vessel has been eroded. In the instances in which the sputa are blood- 
tinged or when the blood is in smaller quantities, bleeding comes by 
diapedesis from hyperaemic vessels. In such cases the haemorrhage may be 
beneficial in relieving the congested blood-vessels. 

The indications are to reduce the frequency of the heart-beats and to 
lower the blood-pressure. Eest of the body and peace of the mind — " quies, 
securitas, silentium " of Celsus — should be secured. Turn the patient on 
the affected side, if known, as the regurgitation is less apt to occur into 
the bronchi of the sound lung. As Aretaeus remarks, in haemoptysis the 
patient despairs from the first, and needs to be strongly reassured. Death 
is rarely due directly to haemoptysis; patients die after, not of it (S. West). 
In the majority of cases of mild haemoptysis this is sufficient. Even 
when the patient insists upon going about, the bleeding may stop spon- 
taneously. The diet should be light and unstimulating. Alcohol should 
not be used. The patient may, if he wishes, have ice to suck. Small 
doses of aromatic sulphuric acid may be given, but unless the bleeding 
is protracted styptic and astringent medicines are not indicated. For 
cough, which is always present and disturbing, opium should be freely 
given, and is of all medicines most serviceable in haemoptysis. Digitalis- 
should not be used, as it raises the blood-pressure in the pulmonary artery. 
Aconite, as it lowers the pressure, may be used when there is much vascu- 
lar excitement. Ergot, tannic acid, and lead, which are so much em- 
ployed, have little or no influence in haemoptysis; ergot probably does harm. 
One of the most satisfactory means of lowering the blood-pressure is purga- 
tion, and when the bleeding is protracted salts may be freely given. In 
profuse haemoptysis, such as comes from erosion of an artery or the rup- 
ture of an aneurism, a fatal result is common, and yet post-mortem evi- 
dence shows that thrombosis may occur with healing in a rupture of con- 
siderable size. The fainting induced by the loss of blood is probably th© 
most efficient means of promoting thrombosis, and it was on this principle 
that formerly patients were bled from the arm, or from both arms, as in 
the case of Laurence Sterne. Ligatures, or Esmarch^s bandages, placed 
around the legs may serve temporarily to check the bleeding. The ice- 
bag on the sternum is of doubtful utility. In a protracted case Cayley in- 
duced pneumothorax, but without effect. 

Briefly, then, we may say that cases of haemorrhage from rupture of 
aneurism or erosion of a blood-vessel usually prove fatal. The fainting 



BRONCHO-PNEUMONIA. 



641 



induced by the loss of blood is beneficial, and, if the patient can be kept 
alive for twenty-four hours, a thrombus of sufficient strength to prevent 
further bleeding may form. The chief danger is the inundation of the 
bronchial system with the blood, so that while the haemorrhage is profuse 
the cough should be encouraged. Opium should not then be used, and 
stimulants should be given with caution. 

In the other group, in which the haemorrhage comes from a congested 
area and is limited, the patient gets well if kept absolutely quiet, and 
fatal haemorrhage probably never occurs from this source. Rest, reduc- 
tion of the blood-pressure by minimum diet, purging, if necessary, and the 
administration of opium to allay the cough are the main indications. 



II. BRONCHO-PNEUMONIA (Capillary Bronchitis). 

This is essentially an inflammation of the terminal bronchus and the 
air-vesicles which make up a pulmonary lobule, whence the term broncho- 
pneumonia. It is also known as lobular, in contradistinction to lobar pneu- 
monia. The term catarrhal is less applicable. The process begins usually 
with an inflammation of the capillary bronchi, which is a condition rarely, 
if ever, found without involvement of the lobular structures, so that it is 
now customary to consider the affections together. All forms of broncho- 
pneumonia depend upon invasion of the lung with microbes, and it would 
have been more consistent to place them with lobar pneumonia among the 
infectious disorders, but it is well perhaps to defer this until the bacteri- 
ology of the different varieties has been more fully worked out. 

Etiology.' — Broncho-pneumonia occurs either as a primary or as a sec- 
ondary affection. The relative frequency in 443 cases is thus given by 
Holt: Primary, without previous bronchitis, 154; secondary (a) to bron- 
chitis of larger tubes, 41; to measles, 89; to whooping-cough, 66; to diph- 
theria, 47; to scarlet fever, 7; to influenza, 6; to varicella, 2; to erysipelas, 
2; and to acute ileo-colitis, 19. The proportion of primary to secondary 
forms as shown in this list is probably too low. 

Primary acute broncho-pneumonia, like the lobar form, attacks children 
in good health, usually under two years. The etiological factors are very 
much those of ordinary pneumonia, and probably the pneumococcus is more 
often associated with it. 

Secondary broncho-pneumonia occurs in two great groups: 1. As a se- 
quence of the infectious fevers — measles, diphtheria, whooping-cough, scar- 
let fever, and, less frequently, small-pox, erysipelas, and typhoid fever. In 
children it forms the most serious complication of these diseases, and in 
reality causes more deaths than are due directly to the fevers. In large 
cities it ranks next in fatality to infantile diarrhoea. Following, as it doc s, 
the contagious diseases which principally affect children, we find that a 
large majority of cases occur during early life. According to Morrill's Bos- 
ton statistics, it is most fatal during the first two years of life. The number 
of cases in a community increases or decreases with the prevalence of 
measles, scarlet fever, and diphtheria. It is most prevalent in the winter 



642 DISEASES OF THE RESPIRATORY SYSTEM. 



and spring months. In the febrile affections of adults broncho-pneumonia 
is not very common. Thus in typhoid fever it is not so frequent as lobar 
pneumonia, though isolated areas of consolidation at the bases are by no 
means rare in protracted cases of this disease. In old people it is an ex- 
tremely common affection, following debilitating causes of any sort, and 
supervening in the course of chronic Bright's disease and various acute and 
chronic maladies. 

2. In the second division of this affection are embraced the cases of 
so-called aspiration or deglutition pneumonia. Whenever the sensitiveness 
of the larynx is benumbed, as in the coma of apoplexy or uraemia, minute 
particles of food or drink are allowed to pass the rima, and, reaching finally 
the smaller tubes, excite an intense inflammation similar to the vagus pneu- 
monia which follows the section of the pneumogastrics in the dog. Cases 
are very common after operations about the mouth and nose, after tracheot- 
omy, and in cancer of the larynx and oesophagus. The aspirated particles 
in some instances induce such an intense broncho-pneumonia that suppura- 
tion or even gangrene supervenes. The ether pneumonia, already described 
(p. 129), is often lobular in type. 

An aspiration broncho-pneumonia may follow haemoptysis (which has 
been already considered), the aspiration of material from a bronchiec- 
tatic cavity, and occasionally the material from an empyema which has 
ruptured into the lung. 

A common and fatal form of broncho-pneumonia is that excited by the 
tubercle bacillus, which has already been considered. 

Among general predisposing causes may be mentioned age. As just 
noted, it is prone to attack infants, and a majority of cases of pneumonia 
in children under five years of age are of this form. Of 370 cases in chil- 
dren under five years of age, 75 per cent were broncho-pneumonia (Holt). At 
the opposite extreme of life it is also common, in association with various de- 
bilitating circumstances and with the chronic diseases incident to the old. 
In children, rickets and diarrhoea are marked predisposing causes, and bron- 
cho-pneumonia is one of the most frequent post-mortem-room lesions in 
infants' homes and foundling asylums. The disease prevails most exten- 
sively among the poorer classes. 

Morbid Anatomy. — On the pleural surfaces, particularly toward the 
base, are seen depressed bluish or blue-brown areas of collapse, between 
which the lung tissue is of a lighter color. Here and there are projecting 
portions over which the pleura may be slightly turbid or granular. The 
lung is fuller and firmer than normal, and, though in great part crepitant, 
there can be felt in places throughout the substance solid, nodular bodies. 
The dark depressed areas may be isolated or a large section of one lobe may 
be in the condition of collapse or atelectasis. Gradual inflation by a blow- 
pipe inserted in the bronchus will distend a great majority of these col- 
lapsed areas. On section, the general surface has a dark reddish color and 
usually drips blood. Projecting above the level of the section are lighter 
red or reddish-gray areas representing the patches of broncho-pneumonia. 
These may be isolated and separated from each other by tracts of unin- 
rlamed tissue or they may be in groups; or the greater part of a lobe may 



BRONCHO-PNEUMONIA. 



643 



be involved. Study of a favorable section of an isolated patch shows: (a) 
A dilated central bronchiole full of tenacious purulent mucus. A fortu- 
nate section parallel to the long axis may show a racemose arrangement — 
the alveolar passages full of muco-pus. (b) Surrounding the bronchus for 
from 3 to 5 mm. or even more, an area of grayish-red consolidation, usu- 
ally elevated above the surface and firm to the touch. Unlike the con- 
solidation of lobar pneumonia, it may present a perfectly smooth surface, 
though in some instances it is distinctly granular. In a late stage of the 
disease small grayish-white points may be seen, which on pressure may be 
squeezed out as purulent droplets. A section in the axis of the lobule may 
present a somewhat grape-like arrangement, the stalks and stems repre- 
senting the bronchioles and alveolar passages filled with a yellowish or 
grayish-white pus, while surrounding them is a reddish-brown hepatized 
tissue, (c) In the immediate neighborhood of this peribronchial inflam- 
mation the tissue is dark in color, smooth, airless, at a somewhat lower 
level than the hepatized portion, and differs distinctly in color and ap- 
pearance from the other portions of the lung. This is the condition to 
which the term splenization has been given. It really represents a tissue 
in the early stage of inflammation, and it perhaps would be as well to give 
up the use of this term and also that of carniftcation, which is only a more 
advanced stage. The condition of collapse probably always precedes this, 
and it is difficult in some instances to tell the difference, as one shades into 
the other. In fact, collapse, splenization, and carnincation are but prelim- 
inary steps in broncho-pneumonia. 

While, in many cases, the areas of broncho-pneumonia present a red- 
dish-brown color and are indistinctly granular, in others, particularly in 
adults, the nodules may resemble more closely gray hepatization and the 
air-cells are filled with a grayish, muco-purulent material. Minute haem- 
orrhages are sometimes seen in the neighborhood of the inflamed areas or 
on the pleural surfaces. Emphysema is commonly seen at the anterior 
borders and upper portions of the lung or in lobules adjacent to the in- 
flamed ones. In many cases following diphtheria and measles the process 
is so extensive that the greater part of a lobe is involved, and it looks like 
a case of lobar hepatization. It has not, however, the uniformity of this 
affection, and collapsed dark strands may be seen between extensive areas 
of hepatized tissue. 

There are three groups of cases: (1) Those in which the bronchitis and 
bronchiolitis are most marked, and in which there may be no definite con- 
solidation, and yet on microscopical examination many of the alveolar pas- 
sages and adjacent air-cells appear filled with inflammatory products. (2) 
The disseminated broncho-pneumonia, in which there are scattered areas 
of peribronchial hepatization with patches of collapse, while a considerable 
proportion of the lobe is still crepitant. This is by far the most common 
condition. (3) The pseudo-lobar form, in which the greater portion of the 
lobe is consolidated, but not uniformly, for intervening strands of dark 
congested lung tissue separate the groups of hepatized lobules. 

Microscopically, the centre of the bronchus is seen filled with a plug 
of exudation, consisting of leucocytes and swollen epithelium. Section in 



DISEASES OF THE RESPIRATORY SYSTEM. 



the long axis may show irregular dilatations of the tribe. The bronchial 
wall is swollen and infiltrated with cells. Under a low power it is readily 
seen that the air-cells next the bronchns are most densely filled, while 
toward the periphery of the focus the alveolar exudation becomes less. The 
contents of the air-cells are made up of leucocytes and swollen endothelial 
cells in varying proportions. Eed corpuscles are not often present and a 
fibrin network is rarely seen, though it may be present in some alveoli. In 
the swollen walls are seen distended capillaries and numerous leucocytes. 
As Delafield has pointed out, the interstitial inflammation of the bronchi 
and alveolar walls is the special feature of broncho-pneumonia. 

The histological changes in the aspiration or deglutition broncho-pneu- 
monia differ from the ordinary post-febrile form in a more intense infiltra- 
tion of the air-cells with leucocytes, producing suppuration and foci of 
softening; even gangrene may be present. 

Bacteriology of Broncho- pneumonia. — The organisms most commonly 
found in broncho-pneumonia are the micrococcus lanceolatus, the strepto- 
coccus pyogenes (either alone or with- the pneumococcus), the staphylococcus 
aureus et albus, and Friedlander's bacillus pneumoniae. The Klebs- 
Loeffler bacillus is not infrequently found in the secondary lesions of 
diphtheria. Except the pneumococcus these microbes are rarely found in 
pure cultures. In the lobular type the streptococcus is the most constant 
organism, in the pseudo-lobar the pneumococcus. Mixed infections are al- 
most the rule in broncho-pneumonia. 

M. Wollstein, in 17 primary cases, found the micrococcus lanceolatus 
alone in 9, with the streptococcus in 7. Of 14 secondary cases the micro- 
coccus lanceolatus was found alone in 2 and with other organisms in 9. The 
primary form is the result of infection with the pneumococcus, the sec- 
ondary most often with the streptococcus. 

Terminations of Broncho-pneumonia. — (1) In resolution, which when it 
once begins goes on more rapidly than in fibrinous pneumonia. Broncho- 
pneumonia of the apices, in a child, persisting for three or more weeks, 
particularly if it follows measles or diphtheria, is often tuberculous. In 
these instances, when resolution is supposed to be delayed, caseation has in 
reality taken place. (2) In suppuration, which is rarely seen apart from 
the aspiration and deglutition forms, in which it is extremely common. (3) 
In gangrene, which occurs under the same conditions. (4) In fibroid 
changes — chronic broncho-pneumonia — a rare termination in the simple, a 
common sequence of the tuberculous, disease. Formerly it was thought 
that one of the most common changes in broncho-pneumonia, particularly 
in children, was caseation; but this is really a tuberculous process, the 
natural termination of an originally specific broncho-pneumonia. It is of 
course quite possible that a broncho-pneumonia, simple in its origin, may 
subsequently be the seat of infection by the bacillus tuberculosis. 

Symptoms. — The primary form sets in abruptly with a chill or a con- 
vulsion. The child has not had a previous illness, but there may have been 
slight exposure. The temperature rises rapidly and is more constant; the 
physical signs are more local and there is not the widespread diffuse catarrh 
of the smaller tubes. Many cases are mistaken for lobar pneumonia. In 



BBONCHO-PNEUMONIA. 



645 



'-others the pulmonary features are in the background or are overlooked in 
the intensity of the general or cerebral symptoms. The termination is often 
by crisis, and the recovery is prompt. The mortality of this form is slight. 
S. West has recently (British Medical Journal, 1898, i) called attention to 
the importance of recognizing these primary cases and to their resemblance 
in clinical features with acute lobar pneumonia. The secondary form begins 
usually as a bronchitis of the smaller tubes. Much confusion has arisen 
.from the description of capillary bronchitis as a separate affection, whereas 
it is only a part, though a primary and important one, of broncho-pneu- 
monia. At the outset it may be said that if in convalescence from measles 
or in whooping-cough a child has an accession of fever with cough, rapid 
pulse, and rapid breathing, and if, on auscultation, fine rales are heard at 
the bases, or widely spread throughout the lungs, even though neither con- 
solidation nor blowing breathing can be detected, the diagnosis of broncho- 
pneumonia may safely be made. I have never seen in a fatal case after 
•diphtheria or measles a capillary bronchitis as the sole lesion. The onset 
is rarely sudden, or with a distinct chill; but after a day or so of indispo- 
sition the child gets feverish and begins to cough and to get short of breath. 
The fever is extremely variable; a range of from 102° to 10-±° is common. 
The skin is very dry and pungent. The cough is hard, distressing, and 
may be painful. Dyspnoea gradually becomes a prominent feature. Ex- 
piration may be jerky and grunting. The respirations may rise as high 
as 60 or even 80 per minute. Within the first forty-eight hours the per- 
cussion resonance is not impaired; the note, indeed, may be very full at the 
anterior borders of the lungs. On auscultation, many rales are heard, 
chiefly the fine subcrepitant variety, with sibilant rhonchi. There may 
really be no signs indicating that the parenchyma of the lung is involved, 
and yet even at this early stage, within forty-eight hours of the onset of the 
pulmonary symptoms, I have repeatedly, after diphtheria, found scattered 
nodules of lobular hepatization. Northrup, in a case in which death oc- 
curred within the first twenty-four hours, in addition to the extensive in- 
volvement of the smaller bronchi, found the intralobular tissue also in- 
volved in places. The dyspnoea is constant and progressive and soon signs 
of deficient aeration of the blood are noted. The face becomes a little suf- 
fused and the finger-tips bluish. The child has an anxious expression and 
gradually enters upon the most distressing stage of asphyxia. At first the 
urgency of the symptoms is marked, but soon the benumbing influence of 
the carbon dioxide on the nerve-centres is seen and the child no longer makes 
strenuous efforts to breathe. The cough subsides and, with a gradual in- 
crease in lividity and a drowsy restlessness, the right ventricle becomes more 
and more distended, the bronchial rales become more liquid as the tubes 
fill with mucus, and death occurs from heart paralysis. These are symp- 
toms of a severe case of broncho-pneumonia, or what the older writers called 
suffocative catarrh. 

The physical signs may at first be those of capillary bronchitis, as in- 
dicated by the absence of dulness, the presence of fine subcrepitant and 
whistling rales. In many cases death takes place before any definite pneu- 
monic signs are detected. When these exist they are much more frequent 



646 



DISEASES OF THE RESPIRATORY SYSTEM. 



at the bases, where there may be areas of impaired resonance or even of 
positive dulness. When numerous foci involve the greater part of a lobe 
the breathing may become tubular, but in the scattered patches of ordi- 
nary broncho-pneumonia, following the fevers, the breathing is more com- 
monly harsh than blowing. In grave cases there is retraction of the base 
of the sternum and of the lower costal cartilages during inspiration, point- 
ing to deficient lung expansion. 

Diagnosis. — With lobar pneumonia it may readily be confounded if 
the areas of consolidation are large and merged together. It is to be re- 
membered, as Holt's figures well show, that broncho-pneumonia occurs, 
chiefly in children under one year, whereas lobar pneumonia is more common 
after the third year. No writer has so clearly brought out the difference 
between pneumonia at these periods as Gerhard,* of Philadelphia, whose 
papers on this subject, though published nearly sixty years ago, have the 
freshness and accuracy which characterize all the writings of that eminent 
physician. Between lobar pneumonia and the secondary form of broncho- 
pneumonia the diagnosis is easy. The mode of onset is essentially different 
in the two infections, the one developing insidiously in the course or at the- 
conclusion of another disease, the other setting in abruptly in a child in- 
good health. In lobar pneumonia the disease is almost always unilateral,, 
in broncho-pneumonia bilateral. The chief trouble arises in cases of pri- 
mary broncho-pneumonia, which by aggregation of the foci involves the- 
greater part of one lobe. Here the difficulty is very great, and the physical 
signs may be practically identical, but in broncho-pneumonia it is much 
more likely that a lesion, however slight, will be found on the other side. 

A still more difficult question to decide is whether an existing broncho- 
pneumonia is simple or tuberculous. In many instances the decision can- 
not be made, as the circumstances under which the disease occurs, the 
mode of onset, and the physical signs may be identical. It has often been 
my experience that a case has been sent down from the children's ward to- 
the dead-house with the diagnosis of post-febrile broncho-pneumonia in 
which there was no suspicion of the existence of tuberculosis; but on sec- 
tion there were found tuberculous bronchial glands and scattered areas of 
broncho-pneumonia, some of which were distinctly caseous, while others 
showed signs of softening. I have already spoken fully of this in the sec- 
tion on tuberculosis, but it is well to emphasize the fact that there are 
many cases of broncho-pneumonia in children which time alone enables 
us to distinguish from tuberculosis. The existence of extensive disease 
at the apices or central regions is a suggestive indication, and signs of soft- 
ening may be detected. In the vomited matter, which is brought up after 
severe spells of coughing, sputum may be picked out and elastic tissue and 
bacilli detected. 

It is a superfluous refinement to make a diagnosis between capillary 
bronchitis and catarrhal pneumonia, for the two conditions are part and 
parcel of the same disease. In simple bronchitis involving the larger tubes 
urgent dyspnoea and pulmonary distress are rarely present and the rales 



* American Journal of the Medical Sciences, vols, xiv and xv. 



BRONCHO-PNEUMONIA. 



647 



are coarser and more sibilant. It must not be forgotten that, as in lobar 
pneumonia, cerebral symptoms may mask the true nature of the disease, 
and may even lead to the diagnosis of meningitis. I recall more than one 
instance in which it could not be satisfactorily determined whether the 
infant had tuberculous meningitis or a cerebral complication of an acute 
pulmonary affection. 

Prognosis. — In the primary form the outlook is good. In children 
enfeebled by constitutional disease and prolonged fevers broncho-pneumonia 
is terribly fatal, but in cases coming on in connection with whooping- 
cough or after measles recovery may take place in the most desperate cases. 
It is in this disease that the truth of the old maxim is shown — " Never 
despair of a sick child." The death-rate in children under five has been 
variously estimated at from 30 to 50 per cent. After diphtheria and 
measles thin, wiry children seem to stand broncho-pneumonia much better 
than fat, flabby ones. In adults the aspiration or deglutition pneumonia 
is a very fatal disease. 

Prophylaxis. — Much can be done to reduce the probability of attack 
after febrile affections. Thus, in the convalescence from measles and 
whooping-cough, it is very important that the child should not be exposed 
to cold, particularly at night, when the temperature of the room naturally 
falls. In a nocturnal visit to the nursery — sometimes, too, I am sorry to 
say, to a children's hospital — hovv; often one sees children almost naked, 
having kicked aside the bedclothes and having the night-clothes up about 
the arms! The use of light flannel "combinations" obviates this noctur- 
nal chill, which is, I am sure, an important factor in the colds and pulmo- 
nary affections of young children, both in private houses and in institu- 
tions. The catarrhal troubles of the nose and throat should be carefully 
attended to, and during fevers the mouth should be washed two or three 
times a day with an antiseptic solution. 

Treatment. — The frequency and the seriousness of broncho-pneu- 
monia render it a disease which taxes to the utmost the resources of the 
practitioner. There is no acute pulmonary affection over which he at times 
so greatly despairs. On the other hand, there it not one in which he will 
be more gratified in saving cases which have seemed past all succor. The 
general arrangements should receive special attention. The room should 
be kept at an even temperature — about 65° to 68° — and the air should be 
kept moist with vapor. 

At the outset the bowels should be opened by a mild purge, either 
castor oil or small doses of calomel, one twelfth to one sixth of a grain 
hourly until a movement is obtained, and care should be taken throughout 
the attack to secure a daily movement. The common saline fever mixture 
of citrate of potash, liquor ammonii acetatis, and aromatic spirits of am- 
monia may be given every two or three hours. If the disease comes on 
abruptly with high fever, minim or minim and a half doses of the tincture 
of aconite may be given with it. The pain, the distressing symptoms, and 
the incessant cough often demand opium, which must of course be used 
with care and judgment in the case of young children, but which is cer- 
tainly not contra-indicated and may be usefully given in the form of 



«648 



DISEASES OF THE RESPIRATORY SYSTEM. 



Dover's powder. Blisters are now rarely if ever employed, and even the 
jacket poultice has gone out of fashion. For the latter, however, I con- 
Jess to a strong prejudice, and when lightly made and frequently changed 
it undoubtedly gives great relief. Much more commonly we now see, 
both in private and in hospital practice, the jacket of cotton-batting. 
Ice-poultices to the chest I have seen used apparently with great bene- 
fit, and they are warmly recommended by many German physicians as 
well as by Goodhart and others in England. The diet should consist 
of milk, broths, and egg albumen. Milk often curds and is disagreeable. 
Egg-white is particularly suitable and very acceptable when given in cold 
-water with a little sugar. It forms, indeed, an excellent medium for the ad- 
ministration of the stimulants. If the pulse shows signs of failing, it is best 
to begin early with brandy. As in all febrile affections of children, cold 
water should be constantly at the bedside, and the child should be encour- 
aged to drink freely. With these measures, in many cases the disease pro- 
gresses to a favorable termination, but too often other and more serious 
• symptoms arise. Cough becomes more distressing, dyspnoea increases, the 
■ominous rattling of the mucus can be heard in the tubes, the child's color 
is not so good, and there is greater restlessness. Under these circum- 
stances stimulant expectorants — ammonia, squills, and senega — should be 
given. Together they make a very disagreeable dose for a young child, 
particularly with the carbonate of ammonia. The aromatic spirits of am- 
:monia is somewhat better. If the carbonate is employed, it must be given 
in small doses, not more than a grain to an infant of eighteen months. If 
the child has increasing difficulty in getting up the mucus, an emetic 
should be given — either the wine of ipecac or, if necessary, tartar emetic. 
There is no necessity, however, to keep the child constantly nauseated. 
Enough should be given to cause prompt emesis, and the benefit results in 
the expulsion of mucus from the larger tubes. In this stage, too, strych- 
nine is undoubtedly helpful in stimulating the depressed respiratory cen- 
tre. With commencing cyanosis, inhalations of oxygen may be employed, 
sometimes with great benefit. 

With rapid failure of the heart, loud mucous rattles in the throat, and 
increasing lividity, every measure should be used to arouse the child and 
excite coughing. Alternate douches of hot and cold water, electricity, 
which I have seen applied with good results at Wiederhofer's clinic in 
Vienna, and hypodermic injections of ether may be tried. For the reduc- 
tion of temperature, particularly if cerebral symptoms are prominent, there 
is nothing so satisfactory as the wet pack or the cold bath. In the case 
•of children, when the latter is used it should be graduated, beginning with 
a temperature which is pleasantly warm and gradually reducing it to 75° 
or 80°. Even when the temperature is not high, the cerebral s} T mptoms 
■are greatly relieved by the bath or the pack. 



CHRONIC INTERSTITIAL PNEUMONIA. 



649 



III. CHRONIC INTERSTITIAL PNEUMONIA 

{Cirrhosis of the Lung — Fibroid Phthisis). 

This consists in the gradual substitution to a greater or less extent of 
connective tissue for the normal lung. It is a fibroid change which may 
have its starting-point in the tissue about the bronchi and blood-vessels, 
the interlobular septa, the alveolar walls, or in the pleura. So diverse are 
the different forms and so varied the conditions under which this change 
-occurs that a proper classification is extremely difficult. We may recog- 
nize, however, two chief forms — the local, which involves only a limited 
area of the lung substance, and the diffuse, invading either both lungs or 
an entire organ. 

Etiology. — Local fibroid change in the lungs is common. It is a 
constant accompaniment of tubercle and in every case of phthisis the 
chronic interstitial changes play a very important role. In tumors, ab- 
scess, gummata, hydatids, and emphysema it also occurs. Fibroid pro- 
cesses are frequently met with at the apices of the lung and may be due 
either to a limited healed tuberculosis, to fibroid induration in conse- 
quence of pigment, or, in a few instances, may result from thickening of 
the pleura. They have been described at page 331. 

Diffuse interstitial pneumonia is met with under the following cir- 
cumstances: 1. As a sequence of acute fibrinous pneumonia. Although 
•extremely rare, this is recognized as a possible termination. From un- 
known causes resolution fails to take place. A gradual process of organ- 
ization goes on in the fibrinous plugs within the air-cells and the alveolar 
walls become greatly thickened by a new growth, first of nuclear and 
subsequently of fibrillated connective tissue. Macroscopically there is pro- 
duced a smooth, grayish, homogeneous tissue which has the peculiar trans- 
lucency of all new-formed connective tissue. This has been called gray in- 
duration. A majority of the cases terminate within a few months, and in- 
stances which have been followed from the outset are very rare. 

2. Chronic Bronclio-Pneumonia. — The relation of broncho-pneumonia 
to cirrhosis of the lung has been specially studied by Charcot, who states 
that it may follow the acute or subacute form of this disease, particularly in 
children. The fibrosis extends from the bronchi, which are usually found 
dilated. Bronchiectasis itself may be followed by fibrosis of the lung. 
The alveolar walls are thickened and the lobules converted into firm gray- 
ish masses, in which there is no trace of normal lung tissue. This process 
may go on and involve an entire lobe or even the whole lung. Many of 
these cases are tuberculous from the outset. 

3. Pleurogenous Interstitial Pneumonia. — Charcot applies this term 
to that form of cirrhosis of the lung which follows invasion from the pleura. 
Doubl lias been expressed by some writers whether tin's really occurs. 
While Wilson Fox is probably eorred in questioning whether an entire 
lung can become cirrhosed by the gradual invasion from the pleura, there 
can be no doubt that there are instances of primitive dry pleurisy, which. 



650 



DISEASES OF THE RESPIRATORY SYSTEM. 



as Sir Andrew Clark has pointed out, gradually compresses the lung and 
at the same time leads to interstitial cirrhosis. This may be due in part 
to the fibroid change which follows prolonged compression. In some 
cases there seems to be a distinct connection between the greatly thick- 
ened pleura and the dense strands of fibrous tissue passing from it into 
the lung substance. Instances occur in which one lobe or the greater 
part of it presents, on section, a mottled appearance, owing to the in- 
creased thickness of the interlobar septa — a condition which may exist 
without a trace of involvement of the pleura. In many other cases, 
however, the extension seems to be so definitely associated with pleurisy 
that there is no doubt as to the causal connection between the two 
processes. In these instances the lung is removed with great difficulty, 
owing to the thickness and close adhesion of the pleura to the chest 
wall. 

4. Chronic interstitial pneumonia, due to inhalation of dust, which is 
considered in a separate section. 

5. Syphilis of the lung presents the features of a chronic fibrosis of the 
organ (see p. 247). 

6. Indurative changes in the lung may follow the compression by 
aneurism or new growth or the irritation of a foreign body in a bronchus. 

Morbid Anatomy. — There are two chief forms, the massive or lobar 
and the insular or broncho-pneumonic form. In the massive type the dis- 
ease is unilateral; the chest of the affected side is sunken, deformed, and the 
shoulder much depressed. On opening the thorax the heart is seen drawn 
far over to the affected side. The unaffected lung is emphysematous and 
covers the greater portion of the mediastinum. It is scarcely credible in 
how small a space, close to the spine, the cirrhosed lung may lie. The 
adhesions between the pleural membranes may be extremely dense and 
thick, particularly in the pleurogenous cases; but when the disease has 
originated in the lung there may be little thickening of the pleura. The 
organ is airless, firm, and hard. It strongly resists cutting, and on section 
shows a grayish fibroid tissue of variable amount, through which pass the 
blood-vessels and bronchi. The latter may be either slightly or enor- 
mously dilated. There are instances in which the entire lung is converted 
into a series of bronchiectatic cavities and the cirrhosis is apparent only 
in certain areas or at the root. The tuberculous cases can usually be dif- 
ferentiated by the presence of an apical cavity, not bronchiectatic, and 
often large; and the other lung almost invariably shows tuberculous 
lesions. Pulmonary aneurisms are not infrequent in the cavities. The 
other lung is always greatly enlarged and emphysematous. The heart is 
hypertrophied, particularly the right ventricle, and there may be marked 
atheromatous changes in the pulmonary artery. An amyloid condition 
of the viscera is found in some cases. 

In the broncho-pneumonic form the areas are smaller, often centrally 
placed, and most frequently in the lower lobes. They are deeply pigmented, 
show dilated bronchi, and when multiple are separated by emphysematous 
lung tissue. 

A reticular form of fibrosis of the lung has been described by Percy 



CHRONIC INTERSTITIAL PNEUMONIA. 



651 



Kidd and W. McCollum, in which the lungs are intersected by grayish 
fibroid strands following the lines of the interlobular septa. 

Symptoms and Course. — The disease is essentially chronic, ex- 
tending over a period of many years, and when once the condition is estab- 
lished the health may be fairly good. In a well-marked case the patient 
complains only of his chronic cough, perhaps a slight shortness of breath. 
In other respects he is quite well, and is usually able to do light work. 
The cases are commonly regarded as phthisical, though there may be 
scarcely a symptom of that affection except the cough. There are in- 
stances, however, of fibroid phthisis which cannot be distinguished from 
cirrhosis of the lung except by the presence of tubercle bacilli in the 
expectoration. As the bronchi are usually dilated, the symptoms and 
physical signs may be those of bronchiectasis. The cough is paroxysmal 
and the expectoration is generally copious and of a muco-purulent or sero- 
purulent nature. It is sometimes fetid. Haemorrhage is by no means 
infrequent, and occurred in more than one half of the cases analyzed by 
Bastian. Walking on the level and in the ordinary affairs of life the patient 
may show no shortness of breath, but in the ascent of stairs and on exer- 
tion there may be dyspnoea. 

Physical Signs. — Inspection. — The affected side is immobile, retracted, 
and shrunken, and contrasts in a striking way with the voluminous sound 
side. The intercostal spaces are obliterated and the ribs may even over- 
lap. The shoulder is drawn down and from behind it is seen that the 
spine is bowed. The heart is greatly displaced, being drawn over by the 
shrinkage of the lung to the affected side. When the left lung is affected 
there may be a large area of visible impulse in the second, third, and 
fourth interspaces. Mensuration shows a great diminution in the affected 
side, and with the saddle-tape the expansion may be seen to be negative. 
The percussion note varies with the condition of the bronchi. It may be 
absolutely flat, particularly at the base or at the apex. In the axilla 
there may be a flat tympany or even an amphoric note over a large sac- 
culated bronchus. On the opposite side the percussion note is usually 
hyperresonant. On auscultation the breath-sounds have either a cavern- 
ous or amphoric quality at the apex, and at the base are feeble, with 
mucous, bubbling rales. The voice-sounds are usually exaggerated. Car- 
diac murmurs are not uncommon, particularly late in the disease, when 
the right heart fails. These are, of course, the physical signs of the dis- 
ease when it is well established. They naturally vary considerably, ac- 
cording to the stage of the process. The disease is essentially chronic, 
and may persist for fifteen or twenty years. Death occurs sometimes from 
haemorrhage, more commonly from gradual failure of the right heart with 
dropsy, and occasionally from amyloid degeneration of the organs. 

The diagnosis is never difficult. It may be impossible to say, without 
a clear history, whether the origin is pleuritic or pneumonic. Between 
cases of this kind and fibroid phthisis it is not always easy to discriminate, 
as the conditions may be almost identical. When tuberculosis is present, 
however, even in long-standing cases, bacilli are usually present in the 
sputa, and there may be signs of disease in the other lung. 



652 



DISEASES OF THE RESPIRATORY SYSTEM. 



Treatment. — It is only for an intercurrent affection or for an aggra- 
vation of the cough that the patient seeks relief. Nothing can be done 
for the condition itself. When possible the patient should live in a mild 
climate, and should avoid exposure to cold and damp. A distressing 
feature in some cases is the putrefaction of the contents of the dilated 
tubes, for which the same measures may be used as in fetid bronchitis. 



IV. PNEUMONOKONIOSIS. 

Under this term, introduced by Zenker, are embraced those forms of 
fibrosis of the lung due to the inhalation of dusts in various occupations. 
They have received various names, according to the nature of the inhaled 
particles — anthracosis, or coal-miner's disease; siderosis, due to the inhala- 
tion of metallic dusts, particularly iron; chalicosis, due to the inhalation 
of mineral dusts, producing the so-called stone-cutter's phthisis, or the 
" grinders rot " of the Sheffield workers. 

The dust particles inhaled into the lungs are dealt with extensively by 
the ciliated epithelium and by the phagocytes, which exist normally in the 
respiratory organs. The ordinary mucous corpuscles take in a large num- 
ber of the particles, which fall upon the trachea and main bronchi. The 
cilia sweep the mucus out to a point from which it can be expelled by 
coughing. It is doubtful if the particles ever reach the air-cells, but the 
swollen alveolar cells (in which they are in numbers) probably pick them 
up on the way. The mucous and the alveolar cells are the normal respira- 
tory scavengers. In dwellers in the country, in which the air is pure,, 
they are able to prevent the access of dust particles to the lung tissue, 
so that even in adults these organs present a rosy tint, very different from 
the dark, carbonized appearance of the lungs of dwellers in cities. When 
the impurities in the air are very abundant, a certain proportion of the 
dust particles escapes these cells and penetrates the mucosa, reaching the 
lymph spaces, where they are attacked at once by the cells of the connec- 
tive-tissue stroma, which are capable of ingesting and retaining a large quan- 
tity. In coal-miners, coal-heavers, and others whose occupations neces- 
sitate the constant breathing of a very dusty atmosphere even these forces 
are insufficient. Many of the particles enter the lymph stream and, as 
Arnold has shown in his beautiful researches, are carried (1) to the lymph 
nodules surrounding the bronchi and blood-vessels; (2) to the interlobular 
septa beneath the pleura, where they lodge in and between the tissue ele- 
ments; and (3) along the larger lymph channels to the substernal, bronchial 
and tracheal glands, in which the stroma cells of the follicular cords dis- 
pose of them permanently and prevent them from entering the general 
circulation. Occasionally in anthracosis the carbon grains do reach the 
general circulation, and the coal dust is found in the liver and spleen. As 
Weigert has shown, this occurs when the densely pigmented bronchial 
glands closely adhere to the pulmonary veins, through the walls of which 
the carbon particles pass to the general circulation. The lung tissue has 
a remarkable tolerance for these particles, probably because a large propor- 



PNEUMONOKONIOSIS. 



653 



tion of them is warehoused, so to speak, in protoplasmic cells. By con- 
stant exposure a limit is reached, and there is brought about a very definite 
pathological condition, an interstitial sclerosis. In coal-miners this may 
occur in patches, even before the lung tissue is uniformly infiltrated with 
the dust. In others it appears only after the entire organs have become 
so laden that they are dark in color, and an ink-like juice flows from the 
cut surface. The lungs of a miner may be black throughout and yet show 
no local lesions and be everywhere crepitant. 

As already mentioned, the particles are deposited in large numbers in 
the follicular cords of the tracheal and bronchial glands and of the peri- 
bronchial and peri-arterial lymph nodules, and in these they finally excite- 
proliferation of the connective-tissue elements. It is by no means un- 
common to find in persons whose lungs are only moderately carbonized 
the bronchial glands sclerosed and hard. In anthracosis the fibroid 
changes usually begin in the peri-bronchial lymph tissue, and in the early 
stage of the process the sclerosis may be largely confined to these regions.. 
A Nova Scotian miner, aged thirty-six, died under my care, at the Mont- 
real General Hospital, of black small-pox, after an illness of a few days. 
In his lungs (externally coal-black) there were round and linear patches- 
ranging in size from a pea to a hazel-nut, of an intensely black color, air- 
less and firm, and surrounded by a crepitant tissue, slate-gray in color- 
In the- centre of each of these areas was a small bronchus. Many of them 
were situated just beneath the pleura, and formed typical examples of 
limited fibroid broncho-pneumonia. In addition there is usually thicken- 
ing of the alveolar walls, particularly in certain areas. By the gradual, 
coalescence of these fibroid patches large portions of the lung may be 
converted into firm grayish-black, in the case of the coal-miner — steel- 
gray, in the case of the stone-worker — areas of cirrhosis. In the case of a 
Cornish miner, aged sixty-three, who died under my care, one of these 
fibroid areas measured 18 by 6 cm. and 4.5 cm. in depth. 

A second important factor in these cases is chronic bronchitis, which 
is present in a large proportion and really causes the chief symptoms. A 
third is the occurrence of emphysema, which is almost invariably associ- 
ated with long-standing cases of pneumonokoniosis. With the changes so 
far described, unless the cirrhotic area is unusually extensive, the case may 
present the features of chronic bronchitis with emphysema, but finally 
another element comes into play. In the fibroid areas softening occurs,, 
probably a process of necrosis similar to that by which softening is pro- 
duced in fibro-myomata of the uterus. At first these are small and con- 
tain a dark liquid. ■ Charcot calls them ulceres du poumon. They rarely 
attain a large size unless a communication is formed with the bronchus, 
in which case they may become converted into suppurating cavities. The 
question has been much discussed of late as to what part the tubercle bacil- 
lus plays in these cases of pneumonokoniosis with cavity formation. In 
some instances there is certainly a tuberculous process ingrafted, but 
that large excavations may occur, or in other instances bronchiectasis 
withont the presence of bacilli, T have convinced myself by the examina- 
tion of several characteristic specimens. 



654 



DISEASES OF THE RESPIRATORY SYSTEM. 



The sidei*osis induced by the oxide of iron causes an interstitial pneu- 
monia similar to anthracosis. "Workers in brass and in bronze are liable 
to a like affection. 

Chalicosis, due to the deposit of particles of silex and alumina, is 
found in the makers of mill-stones, particularly the French mill-stones, 
and also in knife and axe grinders and stone-cutters. Anatomically, this 
form is characterized by the production of nodules of various sizes, which 
are cut with the greatest difficulty and sometimes present a curious gray- 
ish, even glittering, crystalloid appearance. 

Workers in flax and in cotton, and grain-shovellers are also subject to 
these chronic interstitial changes in the lungs. In all these occupations, 
as shown by Greenhow, to whose careful studies we owe so much of our 
knowledge of these diseases, the condition of the lung may ultimately be 
almost identical. 

The symptoms do not come on until the patient has worked for a vari- 
able number of years in the dusty atmosphere. As a rule there are cough 
and failing health for a prolonged period of time before complete disa- 
bility. The coincident emphysema is responsible in great part for the 
shortness of breath and wheezy condition of these patients. The expec- 
toration is usually muco-purulent. often profuse: in a case of anthra- 
cosis, very dark in color — the so-called " black spit " ; in a case of chalicosis 
there may be seen under the microscope the bright angular particles of 
silica. 

Even when there are physical signs of cavity, tubercle bacillus are not 
necessarily, and indeed in my experience they are not usually present. It 
is remarkable for how long a time a coal-miner may continue to bring up 
sputum laden with coal particles even when there are only signs of a 
chronic bronchitis. Many of the particles are contained in the cells of the 
alveolar epithelium. In these instances it appears that an attempt is made 
by the leucocytes to rid the lungs of some of the carbon grains. 

The diagnosis of the condition is rarely difficult; the expectoration is 
usually characteristic. It must always be borne in mind that chronic 
bronchitis and emphysema form essential parts of the process and that in 
late stages there may be tuberculous infection. 

The treatment of the condition is practically that of chronic bronchitis 
and emphysema. 

V. EMPHYSEMA. 

Definition. — The condition in which the infundibular passages and 
the alveoli are dilated and the alveolar walls atrophied. 

A practical division may be made into compensatory, hypertrophic, 
and atrophic forms, the acute vesicular emphysema, and the interstitial 
forms. The last two do not in reality come under the above definition, but 
for convenience they may be considered here. 



EMPHYSEMA. 



655 



I. COMPENSATOKY EMPHYSEMA. 

Whenever a region of the lung does not expand fully in inspiration, 
either another portion of the lung must expand or the chest wall sink in 
order to occupy the space. The former almost invariably occurs. We 
have already mentioned that in broncho-pneumonia there is a vicarious 
distention of the air- vesicles in the adjacent healthy lobules, and the same 
happens in the neighborhood of tuberculous areas and cicatrices. In gen- 
eral pleural adhesions there is often compensatory emphysema, particu- 
larly at the anterior margins of the lung. The most advanced example of 
this form is seen in cirrhosis, when the unaffected lung increases greatly 
in size^ owing to distention of the air-vesicles. A similar though less 
marked condition is seen in extensive pleurisy with effusion and in pneu- 
mothorax. 

At first, this distention of the air-vesicles is a simple physiological 
process and the alveolar walls are stretched but not atrophied. Ulti- 
mately, however, in many cases they waste and the contiguous air-cells 
fuse, producing true emphysema. 

II. Hypekteophic Emphysema. 

The large-lunged emphysema of Jenner, also known as substantive or 
idiopathic emphysema, is a well-marked clinical affection, characterized by 
enlargement of the lungs, due to distention of the air-cells and atrophy of 
their walls, and clinically by imperfect aeration of the blood and more or 
less marked dyspnoea. 

Etiology. — Emphysema is the result of persistently high intra- 
alveolar tension acting upon a congenitally weak lung tissue. If the 
mechanical views as to its origin, which have prevailed so long, were true, 
the disease would certainly be much more common; since violent respira- 
tory efforts, believed to be the essential factor, are performed by a majority 
of the working classes. Strongly in favor of the view, that the nutritive 
change in the air-cells is the primary factor, is the markedly hereditary 
character of the disease and the frequency with which it starts early in 
life. These are two points upon which scarcely sufficient stress has been 
laid. To James Jackson, Jr., of Boston, we owe the first observations 
on the hereditary character of emphysema. Working under Louis' direc- 
tions, he found that in 18 out of 28 cases one or both parents were af- 
fected. 

I have been impressed by the frequency of its origin in childhood. It 
may follow recurring asthmatic attacks due to adenoid vegetations. It 
may develop, too, in several members of the same family. We are still 
ignorant as to the nature of this congenital pulmonary weakness. Cohn- 
heim thinks it probably due to a defect in the development of the elastic- 
tissue fibres — a statement which is borne out by Eppinger's observations. 

Heightened pressure within the air-cells may be due to forcible in- 
spiration or expiration. Much discussion has taken place as to the part 
played by these two acts in the production of the disease. The inspiratory 
41 



656 



DISEASES OF THE RESPIRATORY SYSTEM. 



theory was advanced by Laennec and subsequently modified by Gairdner, 
who held that in chronic bronchitis areas of collapse were induced, and com- 
pensatory distention took place in the adjacent lobules. This unques- 
tionably does occur in the vicarious or compensatory emphysema, but 
it ^probably is not a factor of much moment in the form now under con- 
sideration. The expiratory theory, which was supported by Mendelssohn 
and Jenner, accounts for the condition in a much more satisfactory way. 
In all straining efforts and violent attacks of coughing, the glottis is closed 
and the chest walls are strongly compressed by muscular efforts, so that 
the strain is thrown upon those parts of the lung least protected, as the 
apices and the anterior margins, in which we always find the emphy- 
sema most advanced. The sternum and costal cartilages gradually yield 
to the heightened intrathoracic pressure and are, in 'advanced cases, pushed 
forward, giving the characteristic rotundity to the thorax. The cartilages 
gradually become calcified. One theory of the disease is that there is a 
gradual enlargement of the thorax and the lungs increase in volume to 
fill up the space. 

Of other etiological factors occupation is the most important. The 
disease is met with in players on wind instruments, in glass-blowers, and 
in occupations necessitating heavy lifting or straining. Whooping-cough 
and bronchitis play an important role, not so much in the changes which 
they induce in the bronchi as in consequence of the prolonged attacks of 
coughing. 

Morbid Anatomy. — The thorax is capacious, usually barrel-shaped, 
and the cartilages are calcified. On removal of the sternum, the anterior 
mediastinum is found completely occupied by the edges of the lungs, and 
the pericardial sac may not be visible. The organs are very large and 
have lost their elasticity, so that they do not collapse either in the thorax 
or when placed on the table. The pleura is pale and there is often an 
absence of pigment, sometimes in patches, termed by Virchow albinism of 
the lung. To the touch they have a peculiar, downy, feathery feel, and 
pit readily on pressure. This is one of the most marked features. Be- 
neath the pleura greatly enlarged air-vesicles may be readily seen. They 
vary in size from ^ to 3 mm., and irregular bulla?, the size of a walnut 
or larger, may project from the free margins. The best idea of the ex- 
treme rarefaction of the tissue is obtained from sections of a lung dis- 
tended and dried. At the anterior margins the structure may form an 
irregular series of air-chambers, lesembling the frog's lung. On careful 
inspection with the hand-lens, remnants of the interlobular septa or even 
of the alveoli may be seen on these large emphysematous vesicles. Though 
general throughout the organs, the distention is more marked, as a rule, 
at the anterior margins, and is often specially developed at the inner sur- 
face of the lobe near the root, where in extreme cases air-spaces as large 
as an egg may sometimes be found. Microscopically there is seen atrophy 
of the alveolar walls, by which is produced the coalescence of neighboring 
air-cells. In this process the capillary network disappears before the 
walls are completely atrophied. The loss of the elastic tissue is a special 
feature. It is stated, indeed, that in certain cases there is a congenital 



EMPHYSEMA. 



657 



defect in the development of this tissue. The epithelium of the air-cells 
undergoes a fatty change, but the large distended air-spaces retain a pave- 
ment layer. 

The bronchi show important changes. In the larger tubes the mucous 
membrane may be rough and thickened from chronic bronchitis; often the 
longitudinal lines of submucous elastic tissue stand out prominently. In 
the advanced cases many of the smaller tubes are dilated, particularly 
when, in addition to emphysema, there are peri-bronchial fibroid changes. 
Bronchiectasis is not, however, an invariable accompaniment of emphy- 
sema, but, as Laennec remarks, it is difficult to understand why it is not 
more common. Of associated morbid changes the most important are 
found in the heart. The right chambers are dilated and hypertrophied, 
the tricuspid orifice is large, and the valve segments are often thickened 
at the edges. In advanced cases the cardiac hypertrophy is general. The 
pulmonary artery and its branches may be wide and show marked atherom- 
atous changes. 

The changes in the other organs are those commonly associated with 
prolonged venous congestion. 

Symptoms. — The disease may be tolerably advanced before any spe- 
cial symptoms develop. A child, for instance, may be somewhat short of 
breath on going up-stairs or may be unable to run and play as other chil- 
dren without great discomfort; or, perhaps, has attacks of slight lividity. 
Doubtless much depends upon the completeness of cardiac compensation. 
When this is perfect, there may be no special interruption of the pulmonary 
circulation and, except with violent exertion, there is no interference with 
the aeration of the blood. In well-developed cases the following are the 
most important symptoms: Dyspnoea, which may be felt only on slight 
exertion, or may be persistent, and aggravated by intercurrent attacks of 
bronchitis. The respirations are often harsh and wheezy, and expiration 
is distinctly prolonged. 

Cyanosis of an extreme grade is more common in emphysema than in 
other affections with the exception of congenital heart-disease. So far as I 
know it is the only disease in which a patient may be able to go about and 
even to walk into the hospital or consulting-room with a lividity of star- 
tling intensity. The contrast between the extreme cyanosis and the com- 
parative comfort of the patient is very striking. In other affections of the 
heart and lungs associated with a similar degree of cyanosis the patient is 
invariably in bed and usually in a state of orthopncea. One condition must 
be here referred to, viz., the extraordinary cyanosis in cases of poisoning 
by. aniline products, which is in most part due to the conversion of the 
haemoglobin into methgemoglobin. 

Bronchitis with associated cough is a frequent symptom and often the 
direct cause of the pulmonary distress. The contrast between emphy- 
sematous patients in the winter and summer is marked in this respect. 
In the latter they may be comfortable and able to attend to their 
work, but with the cold and changeable weather they are laid up with 
attacks of bronchitis. Finally, in fact, the two conditions become in- 
separable and the patient has persistently more or less cough. The acute 



658 



DISEASES OF THE RESPIRATORY SYSTEM. 



bronchitis may produce attacks not unlike asthma. In some instances 
this is true spasmodic asthma, with which emphysema is frequently asso- 
ciated. 

As age advances, and with successive attacks of bronchitis, the condi- 
tion gets slowly worse. In hospital practice it is common to admit pa- 
tients over sixty with well-marked signs of advanced emphysema. The 
affection can generally be told at a glance — the rounded shoulders, barrel 
chest, the thin yet oftentimes muscular form, and sometimes, I think, a very 
characteristic facial expression. 

There is another group, however, of younger patients from twenty-five 
to forty years of age who, winter after winter, have attacks of intense cya- 
nosis in consequence of an aggravated bronchial catarrh. On inquiry we 
find that these patients have been short-breathed from infancy, and they 
belong, I believe, to a category in which there has been a primary defect 
of structure in the lung tissue. 

Physical Signs. — Inspection. — The thorax is markedly altered in shape; 
the antero-posterior diameter is increased and may be even greater than 
the lateral, so that the chest is barrel-shaped. The appearance is some- 
what as if the chest was in a permanent inspiratory position. The sternum 
and costal cartilages are prominent. The lower zone of the thorax looks 
large and the intercostal spaces are much widened, particularly in the hypo- 
chondriac regions. The sternal fossa is deep, the clavicles stand out with 
great prominence, and the neck looks shortened from the elevation of the 
thorax and the sternum. A zone of dilated venules may be seen along the 
line of attachment of the diaphragm. Though this is common in emphy- 
sema, it is by no means peculiar to it or indeed to any special affection. 
Andrew, of Bartholomew's Hospital, and, according to Duckworth, Laycock 
called attention to it. 

The curve of the spine is increased and the back is remarkably rounded, 
so that the scapulae seem to be almost horizontal. Mensuration shows the 
rounded form of the chest and the very slight expansion on deep inspira- 
tion. The respiratory movements, which may look energetic and forcible, 
exercise little or no influence. The chest does not expand, but there is a 
general elevation. The inspiratory effort is short and quick; the expiratory 
movement is prolonged. There may be retraction instead of distention 
in the upper abdominal region during inspiration, and there is sometimes 
seen a transverse curve crossing the abdomen at the level of the twelfth 
rib. The apex beat of the heart is not visible, and there is usually marked 
pulsation in the epigastric region. The cervical veins stand out promi- 
nently and may pulsate. 

Palpation. — The vocal fremitus is somewhat enfeebled but not lost. 
The apex beat can rarely be felt. There is a marked shock in the lower 
sternal region and very distinct pulsation in the epigastrium. Percussion 
gives greatly increased resonance, full and drum-like — what is sometimes 
called hyperresonance. The note is not often distinctly tympanitic in 
quality. The percussion note is greatly extended, the heart dulness may 
be obliterated, the upper limit of liver dulness is greatly lowered, and the 
resonance may extend to the costal margin. Behind, a clear percussion note 



EMPHYSEMA. 



659 



extends to a much lower level than normal. The level of splenic dulness, 
too, may be lowered. 

On auscultation the breath-sounds are usually enfeebled and may be 
masked by bronchitic rales. The most characteristic feature is the pro- 
longation of the expiration, and the normal ratio may be reversed — 4 to 1 
instead of 1 to -±. It is often wheezy and harsh and associated with coarse 
rales and sibilant rhonchi. It is said that in interstitial emphysema there 
may be a friction sound heard, not unlike that of pleurisy. The heart- 
sounds are usually clear; but in advanced cases, when there is marked 
cyanosis, a tricuspid regurgitant murmur may be heard. Accentuation of 
the pulmonary second sound is present. 

The course of the disease is slow but progressive, the recurring attacks 
of bronchitis aggravating the condition. Death may occur from intercur- 
rent pneumonia, either lobar or lobular, and dropsy may supervene from 
cardiac failure. Occasionally death results from overdistention of the heart, 
with extreme cyanosis. Duckworth has called attention to the occasional 
occurrence of fatal haemorrhage in emphysema. In an old emphysematous 
patient at the Montreal General Hospital death followed the erosion of a 
main branch of the pulmonary artery by an ulcer near the bifurcation of the 
trachea. 

Treatment. — Practically, the measures mentioned in connection with 
bronchitis should be employed. In children with asthma and developing 
emphysema the nose should be carefully examined. No remedy is known 
which has any influence over the progress of the condition itself. Bron- 
chitis is the great danger of these patients, and therefore when possible they 
should live in an equable climate. In consequence of the venous engorge- 
ment they are liable to gastric and intestinal disturbance, and it is par- 
ticularly important to keep the bowels regulated and to avoid flatulency 
which often seriously aggravates the dyspnoea. Patients who come into the 
hospital in a state of urgent dyspnoea and lividity, with great engorgement 
of the veins, particularly if they are young and vigorous, should be bled 
freely. On more than one occasion I have saved the lives of persons in this 
condition by venesection. Inhalation of oxygen may be used and the reme- 
dies given already mentioned in connection with bronchitis. Strychnine 
will be found specially useful. 

III. Atrophic Emphysema. 

This is really a senile change and is called by Sir William Jenner small- 
lunged emphysema. It is really a primary atrophy of the lung, coming 
on in advanced life, and scarcely constitutes a special affection. It occurs 
in "withered-looking old persons" who may perhaps have had a winter 
cough and shortness of breath for years. In striking contrast to the essen- 
tial or hypertrophic emphysema, the chest in this form is small. The ribs 
are obliquely placed, the decrease in the diameter being duo to greatly in- 
creased obliquity in the position of the ribs. The thoracic muscles are 
usually atrophied. In advanced cases of this affection the king presents a 
remarkable appearance, being converted into a series of large vesicles, on 



G60 DISEASES OF THE RESPIRATORY SYSTEM. 



the walls of which the remnants of air-cells may be seen. It is a condition 
for which nothing can be done. 

IV. Acute Vesiculab Emphysema. 

When death occurs from bronchitis of the smaller tubes, or from cyanosis 
when strong inspiratory efforts have been made, the lungs are large in vol- 
ume and the air-cells are much distended. Clinically, this condition may 
develop rapidly in cases of cardiac asthma and angina pectoris. The lungs 
are voluminous, the area of pulmonary resonance is much increased, and on 
auscultation there are heard everywhere piping rales and prolonged expira- 
tion. It is the condition to which von Basch has given the names Lungen- 
schwellung and Lungenstarrheit. A similar condition may follow pressure 
on the vagi. 

Y. Intekstitial Emphysema. 

In this form beads of air are seen in the interlobular and subplcural 
tissue; sometimes they form large bullae beneath the pleura. A rare event 
is rupture close to the root of the lung, and the passage of air along the 
trachea into the subcutaneous tissues of the neck. After tracheotomy just 
the reverse may occur and the air may pass from the tracheotomy wound 
along the wind-pipe and bronchi and appear beneath the surface of the 
pleura. From this interstitial emphysema spontaneous pneumothorax may 
arise in healthy persons. 



VI. GANGRENE OF THE LUNG. 

Etiology. — Gangrene of the lung is not an affection per se, but occurs 
in a variety of conditions when necrotic areas undergo putrefaction. It 
it not easy to say why sphacelus should occur in one case and not in an- 
other, as the germs of putrefaction are always in the air-passages, and yet 
necrotic territories rarely become gangrenous. Total obstruction of a pul- 
monary artery, as a rule, causes infarction, and the area shut off does not 
often, though it may, sphacelate. Another factor would seem to be neces- 
sary — probably a lowered tissue resistance, the result of general or local 
causes. It is met with (1) as a sequence of lobar pneumonia. This rarely 
occurs in a previously healthy person — more commonly in the debilitated 
or in the diabetic subject. (2) Gangrene is very prone to follow the as- 
piration pneumonia, since the foreign particles rapidly undergo putrefac- 
tive changes. Of a similar nature are the cases of gangrene due to perfora- 
tion of cancer of the oesophagus into the lung or into a bronchus. (3) The 
putrid contents of a bronchiectatic, more commonly of a tuberculous, cav- 
ity may excite gangrene in the neighboring tissues. The pressure bronchi- 
ectasis following aneurism or tumor may lead to extensive sloughing. (4) 
Gangrene may follow simple embolism of the pulmonary artery. More 
commonly, however, the embolus is derived from a part which is morti- 
fied or comes from a focus of bone disease. In typhus and in typhoid fever 



GANGRENE OF THE LUNG. 



661 



gangrene of the lung may follow thrombosis of one of the larger branches 
of the pulmonary artery. A case occurred in my wards in October, 1897, 
in connection with a typhoid septicaemia. Typhoid bacilli were isolated 
from the lung. Lastly, gangrene of the lung may occur in conditions of 
debility during convalescence from protracted fever — occasionally, indeed, 
without our being able to assign any reasonable cause. 

Morbid Anatomy. — Laennec, who first accurately described pul- 
monary gangrene, recognized a diffuse and a circumscribed form. The for- 
mer, though rare, is sometimes seen in connection with pneumonia, more 
rarely after obliteration of a large branch of the pulmonary artery. It may 
involve the greater part of a lobe, and the lung tissue is converted into a hor- 
ribly offensive greenish-black mass, torn and ragged in the centre. In the 
circumscribed form there is well-marked limitation between the gangrenous 
area and the surrounding tissue. The focus may be single or there may be 
two or more. The lower lobe is more commonly affected than the upper, 
and the peripheral more than the central portion of the lung. A gan- 
grenous area is at first uniformly greenish brown in color; but softening rap- 
idly takes place with the formation of a cavity with shreddy, irregular walls 
and a greenish, offensive fluid. The lung tissue in the immediate neigh- 
borhood shows a zone of deep congestion, often consolidation, and outside 
this an intense oedema. In the embolic cases the plugged artery can some- 
times be found. When rapidly extending, vessels may be opened and a 
copious haemorrhage ensue. Perforation of the pleura is not uncommon. 
The irritating decomposing material usually excites the most intense bron- 
chitis. Embolic processes are not infrequent. There is a remarkable asso- 
ciation in some cases between circumscribed gangrene of the lung and 
abscess of the brain. It has been referred to under the section on bron- 
chiectasis. 

Symptoms and Coarse. — Usually definite symptoms of local pul- 
monary disease precede the characteristic features of gangrene. These, of 
course, are very varied, depending on the nature of the trouble. The sputum 
is very characteristic. It is intensely fetid — usually profuse — and, if ex- 
pectorated into a conical glass, separates into three layers — a greenish-brown, 
heavy sediment; an intervening thin liquid, which sometimes has a greenish 
or a brownish tint; and, on top, a thick, frothy layer. Spread on a glass 
plate, the shreddy debris of lung tissue can readily be picked out. Even 
large fragments of lung may be coughed up. Robertson, of Onancock, 
Va., sent me one several centimetres in length, which had been expecto- 
rated by a lad of eighteen, who had severe gangrene and recovered. Mi- 
croscopically, elastic fibres are found in abundance, with granular matter, 
pigment grains, fatty crystals, bacteria, and leptothrix. It is stated Hint 
clastic tissue is sometimes absent, but I have never met with such an in- 
stance. The peculiar plugs of sputum which occur in bronchiectasy are not 
found. Blood is often present, and, as a rule, is much altered. The spu- 
tum lias, in a majority of the cases, an intensely fetid odor, which is com- 
municated to the breath and may permeate the entire room. It is much 
more offensive than in fetid bronchitis or in abscess of the lung. The 
fetor is particularly marked when there is free communication between the 



662 



DISEASES OF THE RESPIRATORY SYSTEM. 



gangrenous cavities and the bronchi. On several occasions I have found, 
post mortem, localized gangrene, which had been unsuspected during life, 
and in which there had been no fetor of the breath. 

The physical signs, when extensive destruction has occurred, are those 
of cavity, but the limited circumscribed areas may be difficult to detect. 
Bronchitis is always present. 

Among the general symptoms may be mentioned fever, usually of mod- 
erate grade; the pulse is rapid, and very often the constitutional depression 
is severe. But the only special features indicative of gangrene are the 
sputa and the fetor of the breath. The patient generally sinks from exhaus- 
tion. Fatal haemorrhage may ensue. 

Treatment. — The treatment of gangrene is very unsatisfactory. The 
indications, of course, are to disinfect the gangrenous area, but this is often 
impossible. An antiseptic spray of carbolic acid may be employed. A 
good plan is for the patient to use over the mouth and nose an inhaler, 
which may be charged with a solution of carbolic acid or with guaiacol; 
the latter drug has also been used hypodermically, with, it is said, happy 
results in removing the odor. If the signs of cavity are distinct an attempt 
should be made to cleanse it by direct injections of an antiseptic solution. 
If the patient's condition is good and the gangrenous region can be local- 
ized, surgical interference may be indicated. Successful cases have been 
reported. The general condition of the patient is always such as to demand 
the greatest care in the matter of diet and nursing. 



VII. ABSCESS OF THE LUNG. 

Etiology. — Suppuration occurs in the lung under the following con- 
ditions: (1) As a sequence of inflammation, either lobar or lobular. Apart 
from the purulent infiltration this is unquestionably rare, and even in 
lobar pneumonia the abscesses are of small size and usually involve, as 
Addison remarked, several points at the same time. On the other hand, 
abscess formation is extremely frequent in the deglutition and aspiration 
forms of lobular pneumonia. After wounds of the neck or operations 
upon the throat, in suppurative disease of the nose or larynx, occasionally 
even of the ear (Yolkmann), infective particles reach the bronchial tubes 
by aspiration and excite an intense inflammation which often ends in 
abscess. Cancer of the oesophagus, perforating the root of the lung or into 
the bronchi, may produce extensive suppuration. The abscesses vary in 
size from a walnut to an orange, and have ragged and irregular walls, and 
purulent, sometimes necrotic, contents. 

(2) Embolic, so-called metastatic, abscesses, the result of infectious 
emboli, are extremely common in a large proportion of all cases of pyaemia. 
They may occur in enormous numbers and present very definite char- 
acters. As a rule they are superficial, beneath the pleura, and often 
wedge-shaped. At first firm, grayish red in color, and surrounded by a 
zone of intense hyperemia, suppuration soon follows with the forma- 
tion of a definite abscess. The pleura is usually covered with greenish 



NEW GROWTHS IN THE LUNGS. 



663 



lymph, and perforation sometimes takes place with the production of 
pneumothorax. 

(3) Perforation of the lung from without, lodgment of foreign bodies, 
and, in the right lung, perforation from abscess of the liver or a suppurat- 
ing echinococcus cyst are occasional causes of pulmonary abscess* 

(4) Suppurative processes play an important part in chronic pulmonary 
tuberculosis, many of the symptoms of which are due to them. 

Symptoms. — Abscess following pneumonia is easily recognized by 
an aggravation of the general symptoms and by the- physical signs of cavity 
and the characters of the expectoration. Embolic abscesses cannot often 
be recognized, and the local symptoms are generally masked in the gen- 
eral pyaemic manifestations. The characters of the sputum are of great 
importance in determining the presence of abscess. The odor is offensive, 
yet it rarely has the horrible fetor of gangrene or of putrid bronchitis. 
In the pus fragments of lung tissue can be seen, and the elastic tissue may 
be very abundant. The presence of this with the physical signs rarely 
leaves any question as to the nature of the trouble. Embolic cases usually 
run a fatal course. Eecovery occasionally occurs after pneumonia. In a 
case following typhoid fever which I saw at the Garfield Hospital, Kerr 
removed two ribs and found free in the pus of a localized empyema a 
sequestrated piece of lung, the size of the palm of the hand, which had 
sloughed off clearly from the lower lobe. The patient made a good re- 
covery. 

Medicinal treatment is of little avail in abscess of the lung. When 
well defined and superficial, an attempt should always be made to 
open and drain it. A number of successful cases have already been 
treated in this way. 



VIII. NEW GROWTHS IN THE LUNGS. 

Etiology and Morbid Anatomy. — While primary tumors are 
rare, secondary growths are not uncommon. 

The primary growths of the lung are either encephaloid, scirrhus or 
epithelioma. Recent observations show that the last is the most common 
form. Sarcoma also is occasionally found as a primary growth, and still 
more rarely enchondroma. 

The secondary growths may be of various forms. Most commonly they 
follow tumors in the digestive or genito-urinary organs; not infrequently 
also tumors of the bone. There may be encephaloid, scirrhus, epithelioma, 
colloid, melano-sarcoma, enchondroma, or osteoma. 

Primary cancer or sarcoma usually involves only one lung. The sec- 
ondary growths are distributed in both. The primary growth generally 
forms a large mass, which may occupy the greater part of a lung. Occasion- 
ally the secondary growths are solitary and confined chiefly to the pleura. 
The metastatic growths are nearly always disseminated. Occasionally they 
occupy a large portion of the pulmonary tissue. In a case of colloid cancer 
secondary to cancer of the pancreas, I found both lungs voluminous, heavy 



664 



DISEASES OF THE RESPIRATORY SYSTEM. 



only slightly crepitant, and occupied by circular translucent masses, vary- 
ing in size from a pea to a large walnut. 

There are numerous accessory lesions in the pulmonary new growths. 
There may be pleurisy, either cancerous or sero-fibrinous. The effusion 
may be' hemorrhagic, but in 200 cases of cancer, primary or secondary, of 
the lungs and pleura analyzed by Moutard-Martin, hemorrhagic effusion 
occurred in only 12 per cent. The tracheal and bronchial glands are usu- 
ally affected, the cervical glands not infrequently, and occasionally even 
the inguinal. 

The disease is most common in the middle period of life. The pri- 
mary form affects the sexes equally, but secondary cancer is much more 
frequent in women than in men. The conditions which predispose to it 
are quite unknown. It is a remarkable fact that the workers in the 
Schneeberg cobalt mines are very liable to primary cancer of the lungs. 
It is stated that in this region a considerable proportion of all deaths in 
persons over forty are due to this disease. 

Symptoms. — The clinical features of neoplasms of the lungs are by 
no means distinctive, particularly in the case of primary growths. The 
patient may, indeed, as noted by Walshe, present no symptoms pointing 
to intrathoracic disease. Among the more important symptoms are pain, 
particularly when the pleura is involved; dyspnoea, which is apt to be 
paroxysmal when due to pressure upon the trachea; cough, which may be 
dry and painful and accompanied by the expectoration of a dark mucoid 
sputum. This so-called prune- juice expectoration, which was present 10 
times in 18 cases of primary cancer of the lung, was thought by Stokes 
to be of great diagnostic value. 

In many instances there are signs of compression of the large veins, 
producing lividity of the face and upper extremities, or occasionally of 
only one arm. Compression of the trachea and bronchi may give rise to 
urgent dyspnoea. The heart may be pushed over to the opposite side. 
The pneumogastric and recurrent laryngeal nerves are occasionally in- 
volved in the growth. 

Physical Signs. — The patient, according to Walshe, usually lies on 
the affected side. On inspection this side may be enlarged and immo- 
bile and the intercostal spaces are obliterated. This is more commonly 
due to the effusion than to the growth itself. The external lymph- 
glands may be enlarged, particularly the clavicular. The signs, on per- 
cussion and auscultation, are varied, depending much upon the pres- 
ence or absence of fluid. Signs of consolidation are, of course, present; 
the tactile fremitus is absent and the breath-sounds are usually dimin- 
ished in intensity. Occasionally there is typical bronchial breathing. 
Among other symptoms may be mentioned fever, which is present 
in a certain number of cases. Emaciation is not necessarily extreme. 
The duration of the disease is from six to eight months. Occasion- 
ally it runs a very acute course, as noted by Carswell. Cases are re- 
ported in which death occurred in a month or six weeks, and in one in- 
stance (Jaccoud) the patient died in a week from the onset of the symp- 
toms. 



ACUTE PLEURISY. 



665 



Diagnosis. — In secondary growths this is not difficult. The develop- 
ment of pulmonary symptoms within a year or two after the removal of 
a cancer of the breast, or after the amputation of a limb for osteo-sarcoma, 
or the onset of similar symptoms in connection with cancer of the liver, 
or of the uterus, or of the rectum, would be extremely suggestive. In 
primary cases the unilateral involvement, the anomalous character of the 
physical signs, the occurrence of prune-juice expectoration, the progressive 
wasting, and the secondary involvement of the cervical glands are the im- 
portant points in the diagnosis. 

New growths are occasionally primary in the pleura (Harris, Journal 
of Pathology, vol. ii). 

Y. DISEASES OF THE PLEUKA. 
I. ACUTE PLEURISY. 

Anatomically, the cases may be divided into dry or adhesive pleurisy 
and pleurisy with effusion. Another classification is into primary or sec- 
ondary forms. According to the course of the disease, a division may be 
made into acute and chronic pleurisy, and as it is impossible, at present, 
to group the various forms etiologically, this is perhaps the most satisfac- 
tory division. The following forms of acute pleurisy may be considered: 

I. Fibrinous or Plastic Pleurisy. 

In this the pleural membrane is covered by a sheeting of lymph of 
variable thickness, which gives it a turbid, granular appearance, or the 
fibrin may exist in distinct layers. It occurs (1) as an independent affec- 
tion, following cold or exposure. This form of acute plastic pleurisy 
without fluid exudate is not common in perfectly healthy individuals. 
Cases are met with, however, in which the disease sets in with the usual 
symptoms of pain in the side and slight fever, and there are the physical 
signs of pleurisy as indicated by the friction. After persisting for a few 
days, the friction murmur disappears and no exudation occurs. Union 
takes place between the membranes, and possibly the pleuritic adhesions 
which are found in such a large percentage of all bodies examined after 
death originate in these slight fibrinous pleurisies. 

Fibrinous pleurisy occurs (2) as a secondary process in acute diseases 
of the lung, such as pneumonia, which is always accompanied by a certain 
amount of pleurisy, usually of this form. Cancer, abscess, and gangrene 
also cause plastic pleurisy when the surface of the lung becomes involved. 
This condition is specially associated in a large number of cases with 
tuberculosis. Pleural pain, stitch in the side, and a dry cough, with 
marked friction sounds on auscultation arc the initial phenomena in 
many instances of phthisis. The signs are usually basic, but Burney Yeo 
has recently called attention to the frequency with which they occur at 
the apex. 



666 



DISEASES OF THE RESPIRATORY SYSTEM. 



II. Serofibrinous Pleurisy. 

In a majority of cases of inflammation of the pleura there is, with the 
fibrin, a variable amount of fluid exudate, which produces the condition 
known as pleurisy with effusion. 

Etiology. — For generations physicians have considered cold the 
potent factor in inducing pleurisy. This may be true in many cases, but 
modern views of serous inflammations scarcely recognize cold as anything 
more than a predisposing agent, which permits the action of various micro- 
organisms. We have not yet, however, brought all the acute pleurisies into 
the category of microbic affections, and the fact remains that pleurisy 
does follow with great rapidity a sudden wetting or a chill. Of late 
years an attempt has been made, particularly by French writers, to show 
that the majority of acute pleurisies are tuberculous. In this connection 
the following facts may be admitted: (1) In a large number of cases 
of pleurisy coming on abruptly in healthy persons the disease has been 
shown — (a) by post-mortem, in cases of accidental or sudden death, (b) by 
the subsequent history — to be tuberculous; (2) in a larger proportion of 
those cases which come on insidiously in persons who have been in failing 
health or who are delicate the disease is tuberculous from the outset; (3) 
the acute pleurisy, which occurs as a secondary, often a terminal, event in 
chronic affections, such as cirrhosis of the liver, Bright's disease, and can- 
cer, is very frequently tuberculous. I confess that the more carefully I 
have studied the question the larger does the proportion appear to be of 
primary pleurisies of tuberculous origin. The subsequent history of cases 
of acute pleurisy forces us to conclude that in at least two thirds of the 
cases it is a curable affection. This may well be so, according to our pres- 
ent ideas of local tuberculous disease. Several years ago I looked over 
the post-mortem records of 101 successive cases which had died in my wards 
with pleurisy — fibrinous, sero-fibrinous, hemorrhagic, or purulent. Of these, 
there were only 32 in which the pleurisy was definitely tuberculous. One 
of the most interesting contributions to this question has been made from 
the records of Henry I. Bowditch, of Boston. Of 90 cases of acute pleurisy 
which had been under observation between 1849 and 1879, 32 died of or 
had phthisis — a percentage large enough to indicate what an important 
role tuberculosis plays in the etiology of this disease. In a recent series 
of 130 patients with primary pleurisy with effusion followed for a period 
of seven years by Hedges, 40 per cent became tuberculous. 

Bacteriology of Acute Pleurisy. — From a bacteriological standpoint we 
may recognize three groups of cases of acute pleurisy, caused by the tubercle 
bacillus, the pneumococcus, and the streptococcus, respectively. 

Bacillus tuberculosis is present in a very large proportion of all cases 
of primary or so-called idiopathic pleurisy. The exudate is usually sterile 
on cover-slips or in the culture and inoculation tests made in the ordinary 
way, as the bacilli are very scanty. It has been demonstrated clearly 
that a large amount of the exudate must be taken to make the test 
complete, either in cultures or in the inoculation of animals. Eichhorst 



ACUTE PLEURISY. 



6G7 



found that more that 62 per cent were demonstrated as tuberculous when 
as much as 15 cc. of the exudate was inoculated into test animals, while 
less than 10 per cent of the cases showed tuberculosis when only 1 cc. of the 
exudate was used. This is a point to which observers should pay very 
special attention. Le Damany has recently in 55 primary pleurisies demon- 
strated the tuberculous character of all but 4. He has used large quantities 
of the fluid for his inoculation experiments. 

The pneumococcus pleurisy is almost always secondary to a focus of 
inflammation in the lung. It may, however, be primary. The exudate is 
usually purulent and the outlook is very favorable. 

The streptococcus pleurisy is the typical septic form which may occur 
either from direct infection of the pleura, through the lung in broncho- 
pneumonia, or in cases of streptococcus pneumonia; in other instances it 
follows infection of more distant parts. The acute streptococcus pleurisy is 
the most serious and fatal of all forms. 

Among other bacteria which have been found are the staphylococcus, 
Friedlander's bacillus, the typhoid bacillus, and the diphtheria bacillus. 

Morbid Anatomy. — In sero-fibrinous pleurisy the serous exudate is 
abundant and the fibrin is found on the pleural surfaces and scattered 
through the fluid in the form of flocculi. The proportions of these 
constituents vary a great deal. In some instances there is very little 
membranous fibrin; in others it forms thick, creamy layers and exists 
in the dependent part of the fluid as whitish, curd-like masses. The 
fluid of sero-fibrinous pleurisy is of a lemon color, either clear or slightly 
turbid, depending on the number of formed elements. In some instances 
it has a dark-brown color. The microscopical examination of the fluid 
shows leucocytes, occasional swollen cells, which may possibly be derived 
from the pleural endothelium, shreds of fibrillated fibrin, and a variable 
number of red blood-corpuscles. On boiling, the fluid is found to be rich 
in albumin. Sometimes it coagulates spontaneously. Its composition 
closely resembles that of blood-serum. Cholesterin, uric acid, and sugar 
are occasionally found. The amount of the effusion varies from -J to 4 
litres. 

The lung in acute sero-fibrinous pleurisy is more or less compressed. If 
the exudation is limited the lower lobe alone is atelectatic; but in an exten- 
sive effusion which reaches to the clavicle the entire lung will be found 
lying close to the spine, dark and airless, or even bloodless — i. e., car- 
nified. 

In large exudations the adjacent organs are displaced. In large right- 
sided pleurisies the liver is much depressed. Rather varying statements 
are made with reference to the position of the heart and as to whether or 
not it rotates on its axis. In a number of post-mortems I have carefully 
studied its position, both in pneumothorax and in large effusions, and can 
speak with some degree of certainty on the following points: (1) Even in 
the most extensive left-sided exudation there is no rotation of the apex 
of the heart, which in no case was to the right of the mid-sternal line; 
(2) the relative position of the apex and base is usually maintained; in 
some instances the apex is lifted, in others the whole heart lies more trans- 



668 



DISEASES OF THE RESPIRATORY SYSTEM. 



versely; (3) the right chambers of the heart occupy the greater portion of 
the front, so that the displacement is rather a definite dislocation of the 
mediastinum, with the pericardium, to the right, than any special twisting 
of the heart itself; (4) the kink or twist in the inferior vena cava described 
by Bartels was not present in any of the cases. 

Symptoms. — Prodromes are not uncommon, but the disease may set 
in abruptly with a chill, followed by fever and a severe pain in the side. 
In very many cases, however, the onset is insidious. Washbourn has called 
attention to the frequency with which the pneumococcus pleurisy sets in 
with the features of pneumonia. The pain in the side is the most distress- 
ing symptom, and is usually referred to the nipple or axillary regions. It 
must be remembered, however, that pleuritic pain may be felt in the abdo- 
men or low down in the back, particularly when the diaphragmatic sur- 
face of the pleura is involved. It is lancinating, sharp, and severe, and is 
aggravated by cough. At this early stage, on auscultation, sometimes in- 
deed on palpation, a dry friction rub can be detected. The fever rarely 
rises so rapidly as in pneumonia, and does not reach the same grade. A 
temperature of from 102° to 103° is an average pyrexia. It may drop to 
normal at the end of a week or ten days without the appearance of any 
definite change in the physical signs, or it may persist for several weeks. 
The temperature of the affected is higher than that of the sound side. 
Cough is an early symptom in acute pleurisy, but is rarely so distressing or 
so frequent as in pneumonia. There are instances in which it is absent. 
The expectoration is usually slight in amount, mucoid in character, and 
occasionally streaked with blood. 

At the outset there may be dyspnoea, due partly to the fever and partly 
to the pain in the side. Later it results from the compression of the lung, 
particularly if the exudation has taken place rapidly. When, however, 
the fluid is effused slowly, one lung may be entirely compressed without 
inducing shortness of breath, except on exertion, and the patient will lie 
quietly in bed without evincing the slightest respiratory distress. When the 
effusion is large the patient usually prefers to lie upon the affected side. 

Physical Signs. — Inspection shows some degree of immobility on the 
affected side, depending upon the amount of exudation, and in large effu- 
sions an increase in volume, which may appear to be much more than it 
really is as determined by mensuration. The intercostal spaces are obliter- 
ated. In right-sided effusions the apex beat may be lifted to the fourth 
interspace or be pushed beyond the left nipple, or may even be seen in the 
axilla. When the exudation is on the left side, the heart* s impulse may 
not be visible; but if the effusion is large it is seen in the third and fourth 
spaces on the right side, and sometimes as far out as the nipple, or even 
beyond it. 

Palpation enables us more successfully to determine the deficient move- 
ments on the affected side, and the obliteration of the intercostal spaces, 
and more accurately to define the position of the heart's impulse. In sim- 
ple sero-fibrinous effusion there is rarely any oedema of the chest walls. 
It is scarcely ever possible to obtain fluctuation. Tactile fremitus is greatly 
diminished or abolished. If the effusion is slight there may be only en- 



ACUTE PLEURISY. 



669 



feeblement. The absence of the voice vibrations in effusions of any size 
constitutes one of the most valuable of physical signs. In children there 
may be much effusion with retention of fremitus. In rare cases the vibra- 
tions may be communicated to the chest walls through localized pleural 
adhesions. 

Mensuration. — With the cyrtometer, if the effusion is excessive, a dif- 
ference of from half an inch to an inch, or even, in large effusions, an 
inch and a half, may be found between the two sides. Allowance must 
be made for the fact that the right side is naturally larger than the left. 
With the saddle-tape the difference in expansion between the two sides 
can be conveniently measured. 

Percussion. — Early in the disease,, when the pain in the side is severe 
and the friction murmur evident, there may be no alteration, but with 
the gradual accumulation of the fluid the resonance becomes defective, 
and finally gives place to absolute flatness. From day to day the gradual 
increase in height of the fluid may be studied. In a pleuritic effusion 
rising to the fourth rib in front, the percussion signs are usually very 
suggestive. In the subclavicular region the attention is often aroused at 
once by a tympanitic note, the so-called Skoda's resonance, which is heard 
perhaps more commonly in this situation with pleural effusion than in 
any other condition. It shades insensibly into a flat note in the lower 
mammary and axillary regions. Skoda's resonance may be obtained also 
behind, just above the limit of effusion. The dulness has a peculiarly 
resistant, wooden quality, differing from that of pneumonia and readily 
recognized by skilled fingers. It has long been known that when the 
patient is in the erect posture the upper line of dulness is not horizontal, 
but is higher behind than it is in front, forming a parabola. The curve 
marking the intersection of the plane of contact of lung and fluid with 
the chest wall has been variously described. The " Ellis line of flatness/' 
which Garland has verified clinically and by animal experiments, is per- 
haps the most characteristic. With medium-sized effusions " this line begins 
lowest behind, advances upward and forward in a letter-S curve to the 
axillary region, whence it proceeds in a straight decline to the sternum. " 
Such a curve is present only when the patient is in the erect position, 
when the lung is in fairly normal condition, since then by its elastic ten- 
sion it controls the position and shape of the mass of fluid, even supporting 
the entire weight of a considerable exudate, and when the pleura? are free 
from adhesions. With larger exudates the curve flattens much, but the S can 
be detached with the fluid as high as the third rib. Garland emphasizes 
that the line can be accurately determined only by light percussion. (Gar- 
land's exhaustive work on Pneumo-dynamics.) 

On the right side the dulness passes without change into that of the 
liver. On the left side in the nipple line it extends to and may obliterate 
Traube's semilunar space. If the effusion is moderate, the phenomenon 
of movable dulness may be obtained by marking carefully, in the sitting 
posture, the upper limit in the mammary region, and then in the recum- 
bent posture, noting the change in the height of dulness. This infallible 
sign of fluid cannot always be obtained. In very copious exudation the 



670 



DISEASES OF THE RESPIRATORY SYSTEM. 



dulness may reach the clavicle and even extend beyond the sternal margin 
of the opposite side. 

Auscultation. — Early in the disease a friction rub can usually be heard, 
which disappears as the fluid accumulates. It is a to-and-fro dry rub, close 
to the ear, and has a leathery, creaking character. There is another pleural 
friction sound which closely resembles, and is scarcely to be distinguished 
from, the fine crackling crepitus of pneumonia. This may be heard at the 
commencement of the disease, and also, as pointed out in 1844 by Mac- 
Donnell, Sr., of Montreal, when the effusion has receded and the pleural 
layers come together again. 

With even a slight exudation there is weakened or distant breathing. 
Often inspiration and expiration are distinctly audible, though distant, and 
have a tubular quality. Sometimes only a puffing tubular expiration is 
heard, which may have a metallic or amphoric quality. Loud resonant 
rales accompanying this may forcibly suggest a cavity. These pseudo- 
cavernous signs are met with more frequently in children, and often lead 
to error in diagnosis. Above the line of dulness the breath-sounds are usu- 
ally harsh and exaggerated, and may have a tubular quality. 

The vocal resonance is usually diminished or absent. The whispered 
voice is said to be transmitted through a serous and not through a puru- 
lent exudate (Baccelli's sign). This author advises direct auscultation in 
the antero-lateral region of the chest. There may, however, be intensifica- 
tion — bronchophony. The voice sometimes has a curious nasal, squeaking 
character, which was termed by Laennec oegophony, from its supposed re- 
semblance to the bleating of a goat. In typical form this is not common, 
but it is by no means rare to hear a curious twang-like quality in the voice, 
particularly at the outer angle of the scapula. 

In the examination of the heart in cases of pleuritic effusion it is well 
to bear in mind that when the apex of the heart lies beneath the sternum 
there may be no impulse. The determination of the situation of the organ 
may rest with the position of maximum loudness of the sounds. Over the 
displaced organ a systolic murmur may be heard. When the lappet of lung 
over the pericardium is involved on either side there may be a pleuro-peri- 
cardial friction. A leucocytosis is usually present. 

The course of acute sero-fibrinous pleurisy is very variable. After per- 
sisting for a week or ten days the fever subsides, the cough and pain dis- 
appear, and a slight effusion may be quickly absorbed. In cases in which 
the effusion reaches as high as the fourth rib recovery is usually slower. 
Many instances come under observation for the first time, after two or three 
weeks' indisposition, with the fluid at a level with the clavicle. The fever 
may last from ten to twenty days without exciting anxiety, though, as a 
rule, in ordinary pleurisy from cold, as we say, the temperature in cases of 
moderate severity is normal within eight or ten days. Left to itself the 
natural tendency is to resorption; but this may take place very slowly. 
With the absorption of the fluid there is a redux-friction crepitus, either 
leathery and creaking or crackling and rale-like, and for months, or even 
longer, the defective resonance and feeble breathing are heard at the base. 
Rare modes of termination are perforation and discharge through the lung, 



ACUTE PLEURISY. 



671 



and externally through the chest wall, examples of which have been re- 
corded by Sahli. 

The immediate prognosis in pleurisy with effusion is good. Of 320 
cases at St. Bartholomew's Hospital, only 6.1 per cent died before leaving 
the hospital (Hedges). 

A sero-fibrinous exudate may persist for months without change, par-, 
ticularly in tuberculous cases, and will sometimes reaccumulate after aspi- 
ration and resist all treatment. After persistence for more than twelve 
months, in spite of repeated tapping, a serous effusion was cured by inci- 
sion without deformity of the chest (S. West). When one pleura is full and 
the heart is greatly dislocated, the condition, although in a majority of cases 
producing remarkably little disturbance, is not without risk. Sudden death 
may occur, and its possibility under these circumstances should always be 
considered. I have seen two instances — one in right and the other in left 
sided effusion — both due, apparently, to syncope following slight exertion, 
such as getting out of bed. In neither case, however, was the amount of 
fluid excessive. Weil, who has studied carefully this accident, concludes as 
follows: (1) That it may be due to thrombosis or embolism of the heart or 
pulmonary artery, oedema of the opposite lung, or degeneration of the heart 
muscle; (2) such alleged causes as mechanical impediment to the circulation, 
owing to dislocation of the heart or twisting of the great vessels, require 
further investigation. Death may occur without any premonitory symptoms. 

III. Purulent Pleukisy (Empyema). 

Etiology. — Pus in the pleura is met with under the following condi- 
tions: (a) As a sequence of acute sero-fibrinous pleurisy. It is not always 
easy to say why, in certain cases, the exudate becomes purulent. It rarely 
does so in the acute pleurisies of healthy individuals. In children many 
cases are probably purulent from the onset. Aspiration, which is said to 
favor the occurrence of empyema, in my experience does so very rarely. 
(&) Purulent pleurisy is common as a secondary inflammation in various 
infectious diseases, among which scarlet fever takes the first place. It has 
long been known that the pleurisy supervening in the convalescence of this 
disease is almost always purulent. It should be remembered that it is latent 
in its onset, and that there may be no pulmonary symptoms. The pleurisy 
following typhoid fever is also usually purulent. Other infectious diseases 
— measles and whooping-cough — are more rarely followed by this compli- 
cation. Of late years especial attention has been paid to the connection 
of pneumonia with empyema, and it has been shown that very many cases 
come on insidiously either in the course of or during convalescence from 
this disease; and, lastly, a limited number of tuberculous pleurisies early 
become purulent, (c) Empyema results from local causes — fracture of the 
rib, penetrating wounds, malignant disease of the lung or oesophagus, and, 
perhaps most frequently of all, the perforation of the pleura by tuberculous 
cavities. 

The bacteriology of empyema is of great importance. A sterile exudate 
suggests tuberculosis. In many cases the pneumococci are present, and these 
cases, as a rule, run a very favorable course. The streptococci are found 
42 



672 



DISEASES OF THE RESPIRATORY SYSTEM. 



most commonly in the secondary cases in connection with septic processes. 
In a few instances psorosperms have heen present. 

Morbid Anatomy. — On opening an empyema post mortem, we usu- 
ally find that the effusion has separated into a clear, greenish-yellow serum 
ahove and the thick, cream-like pus below. The fluid may be scarcely 
more than turbid, with flocculi of fibrin through it. In the pneumococcal s 
empyema the pus is usually thick and creamy. It usually has a heavy, 
sweetish odor, but in some instances — particularly those following wounds 
— it is fetid. In cases of gangrene of the lung or pleura the pus has a 
horribly stinking odor. Microscopically it has the characters of ordinary 
pus. The pleural membranes are greatly thickened, and present a grayish- 
white layer from 1 to 2 mm. in thickness. On the costal pleura there may 
be erosions, and in old cases fistulous communications are common. The 
lung may be compressed to a very small limit, and the visceral pleura also 
may sliow perforations. 

Symptoms. — Purulent pleurisy may begin abruptly, with the symp- 
toms already described. More frequently it comes on insidiously in the 
course of other diseases or follows an ordinary sero-fibrinous pleurisy. There 
may be no pain in the chest, very little cough, and no dyspnoea, unless the 
side is very full. Symptoms of septic infection are rarely wanting. If 
in a child, there is a gradually developing pallor and weakness; sweats occur, 
and there is irregular fever. A cough is by no means constant. The leu- 
cocytes are usually much increased; in one fatal case they numbered 115,- 
000 per cubic millimetre. 

Physical Signs. — Practically they are those already considered in pleu- 
risy with effusion. There are, however, one or two additional points to be 
mentioned. In empyema, particularly in children, the disproportion be- 
tween the sides may be extreme. The intercostal spaces may not only be 
obliterated, but may bulge. Not infrequently there is oedema of the chest 
walls. The network of subcutaneous veins may be very distinct. It must 
not be forgotten that in children the breath-sounds may be loud and tubular 
over a purulent effusion of considerable size. Whispered pectoriloquy is 
usually not heard in empyema (Baccelli's sign). The dislocation of the 
heart and the displacement of the liver are more marked in empyema than 
in sero-fibrinous effusion — probably, as Senator suggests, owing to the 
greater weight of the fluid. 

A curious phenomenon associated generally with empyema, but which 
may occur in the sero-fibrinous exudate, is pulsating pleurisy, first described 
by MacDonnell, Sr., of Montreal. Of 42 cases 39 occurred on the left side. 
In all but one case the fluid was purulent. Pneumothorax may be present. 
There are two groups of cases, the intrapleural pulsating pleurisy and the 
pulsating empyema necessitatis, in which there is an external pulsating 
tumor. No satisfactory explanation has been offered how the heart im- 
pulse is thus forcibly communicated through the effusion. 

Empyema is a chronic affection, which in a few instances terminates 
naturally in recovery, but a majority of cases, if left alone, end in death. 
The following are some modes of natural cure: (a) By absorption of the 
fluid. In small effusions this may take place gradually. The chest wall 



ACUTE PLEURISY. 



673 



sinks. The pleural layers become greatly thickened and enclose between 
them the inspissated pus, in which lime salts are gradually deposited. Such 
a condition may be seen once or twice a year in the post-mortem room of 
any large hospital, (b) By perforation of the lung. Although in this 
event death may take place rapidly, by suffocation, as Aretseus says, yet 
in cases in which it occurs gradually recovery may follow. Since 1873, 
when I saw a case of this kind in Traube's clinic, and heard his remarks 
on the subject, I have seen a number of instances of the kind and can 
corroborate his statement as to the favorable termination of many of them. 
Empyema may discharge either by opening into the bronchus and forming 
a fistula, or, as Traube pointed out, by producing necrosis of the pulmonary 
pleura, sufficient to allow the soakage of the pus through the spongy lung 
tissue into the bronchi. In the first way pneumothorax usually, though 
not always, develops. In the second way the pus is discharged without 
formation of pneumothorax. Even with a bronchial fistula recovery is pos- 
sible, (c) By perforation of the chest wall — empyema necessitatis. This 
is by no means an unfavorable method, as many cases recover. The per- 
foration may occur anywhere in the chest wall, but is, as Cruveilhier re- 
marked, more common in front. It may be anywhere from the third to 
the sixth interspace, usually, according to Marshall, in the fifth. It may 
perforate in more than one place, and there may be a fistulous communica- 
tion which opens into the pleura at some distance from the external orifice. 
The tumor, when near the heart, may pulsate. The discharge may persist 
for years. In Copeland's Dictionary is mentioned an instance of a Ba- 
varian physician who had a pleural fistula for thirteen years and enjoyed 
fairly good health. 

An empyema may perforate the neighboring organs, the oesophagus, 
peritonaeum, pericardium, or the stomach. Very remarkable cases are those 
which pass clown the spine and along the psoas into the iliac fossa, and 
simulate a psoas or lumbar abcess. 

IV. TUBERCULOUS PlEUKIST. 

This has already been considered (p. 284), and the symptoms and phys- 
ical signs do not require any description other than that already given in 
connection with the sero-fibrinous and purulent forms. 

V. Other Varieties of Pleurisy. 

Hemorrhagic Pleurisy.— A bloody effusion is met with under the fol- 
lowing conditions: (a) In the pleurisy of asthenic states, such as cancer, 
Bright's disease, and occasionally in the malignant fevers. It is interest- 
ing to note the frequency with which hemorrhagic pleurisy is found in 
cirrhosis of the liver. It occurred in the very patient in whom Laennec 
first accurately described this disease. While this may be a simple hemor- 
rhagic pleurisy, in a majority of the cases which I have Been it has been 
tuberculous, (b) Tuberculous pleurisy, in which ihe bloody effusion may 
result from the rupture of newly formed vessels in the soft exudate accom- 



674 



DISEASES OF THE RESPIRATORY SYSTEM. 



panying the eruption of miliary tubercles, or it may come from more slowly 
formed tubercles in a pleurisy secondary to extensive pulmonary disease, 
(c) Cancerous pleurisy, whether primary or secondary, is frequently haamor- 
rhagic. (d) Occasionally hsemoirhagic exudation is met with in perfectly 
healthy individuals, in whom there is not the slightest suspicion of tuber- 
culosis or cancer. In one such case, a large, able-bodied man, the patient 
was to my knowledge healthy and strong eight years afterward. And, 
lastly, it must be remembered that during aspiration the lung may be 
wounded and blood in this way get mixed with the sero-fibrinous exudate. 
The condition of haemorrhagic pleurisy is to be distinguished from haemo- 
thorax, due to the rupture of aneurism or the pressure of a tumor on the 
thoracic veins. 

Diaphragmatic Pleurisy. — The inflammation may be limited partly or 
chiefly to the diaphragmatic surface. This is often a dry pleurisy, but 
there may be effusion, either sero-fibrinous or purulent, which is circum- 
scribed on the diaphragmatic surface. In these cases the pain is low in 
the zone of the diaphragm and may simulate that of acute abdominal dis- 
ease. It may be intensified by pressure at the point of insertion of the 
diaphragm at the tenth rib. The diaphragm is fixed and the respiration 
is thoracic and short. Andral noted in certain cases severe dyspnoea and 
attacks simulating angina. As mentioned, the effusion is usually plastic, 
not serous. Serous or purulent effusions of any size limited to the dia- 
phragmatic surface are extremely rare. Intense subjective with trifling 
objective features are always suggestive of diaphragmatic pleurisy. 

Encysted Pleurisy. — The effusion may be circumscribed by adhesions or 
separated into two or more pockets or loculi, which communicate with each 
other. This is most common in empyema. In these cases there have 
usually been, at different parts of the pleura, multiple adhesions by which 
the fluid is limited. In other instances the recent false membranes may 
encapsulate the exudation on the diaphragmatic surface, for example, or the 
part of the pleura posterior to the mid-axillary line. The condition may 
be very puzzling during life, and present special difficulties in diagnosis. 
In some cases the tactile fremitus is retained along certain lines of adhe- 
sion. The exploratory needle should be freely used. 

Interlobar Pleurisy, forms an interesting and not uncommon variety. 
In nearly every instance of acute pleurisy the interlobular serous surfaces 
are also involved and closely agglutinated together, and sometimes the fluid 
is encysted between them. In this position tubercles are to be carefully 
looked for. In a case of this kind following pneumonia there was between 
the lower and upper and middle lobes of the right side an enormous puru- 
lent collection, which looked at first like a large abscess of the lung. These 
collections may perforate the bronchi, and the cases present special diffi- 
culties in diagnosis. 

Diagnosis of Pleurisy. — Acute plastic pleurisy is readily recog- 
nized. In the diagnosis of pleuritic effusion the first question is, Does a 
fluid exudate exist? the second, What is its nature? In large effusions 
the increase in the size of the affected side, the immobility, the absence of 
tactile fremitus, together with the displacement of organs, give infallible 



ACUTE PLEURISY. 



675 



indications of the presence of fluid. The chief difficulty arises in effusions 
of moderate extent, when the dulness, the presence of bronchophony, and, 
perhaps, tubular breathing may simulate 'pneumonia. The chief points to 
be borne in mind are: (a) Differences in the onset and in the general char- 
acters of the two affections, more particularly the initial chill, the higher 
fever, more urgent dyspnoea, and the rusty expectoration, which charac- 
terize pneumonia. As already mentioned, some of the cases of pneumo- 
coccus pleurisy set in like pneumonia, (b) Certain physical signs — the more 
wooden character of the dulness, the greater resistance, and the marked 
diminution or the absence of tactile fremitus in pleurisy. The auscultatory 
signs may be deceptive. It is usually, indeed, the persistence of tubular 
breathing, particularly the high-pitched, even amphoric expiration, heard 
in some cases of pleurisy, which has raised the doubt. The intercostal 
spaces are more commonly obliterated in pleuritic effusion than in pneu- 
monia. As already mentioned, the displacement of organs is a very valuable 
sign. Nowadays with the hypodermic needle the question is easily settled. 
A separate small syringe with a capacity of two drachms should be reserved 
for exploratory purposes, and the needle should be longer and firmer than 
in the ordinary hypodermic instrument. With careful preliminary disin- 
fection the instrument can be used with impunity, and in cases of doubt 
the exploratory puncture should be made without hesitation. Pneumo- 
thorax is an occasional sequence. The hypodermic needle is especially 
useful in those cases in which there are pseudo-cavernous signs at the base. 
In cases, too, of massive pneumonia, in which the bronchi are plugged with 
fibrin, if the patient has not been seen from the outset, the diagnosis may 
be impossible without it. 

On the left side it may be difficult to differentiate a very large peri- 
cardial from a pleural effusion. The retention of resonance at the base, 
the presence of Skoda's resonance toward the axilla, the absence of dis- 
location of the heart-beat to the right of the sternum, the feebleness of 
the pulse and of the heart-sounds, and the urgency of the dyspnoea, out 
of all proportion to the extent of the effusion, are the chief points to be 
considered. Unilateral hydrothorax, which is not at all uncommon in 
heart-disease, presents signs identical with those of sero-fibrinous effusion. 
Certain tumors within the chest may simulate pleural effusion. It should 
be remembered that many intrathoracic growths are accompanied by exu- 
dation. Malignant disease of the lung and of the pleura and hydatids of 
the pleura produce extensive dulness, with suppression of the breath-sounds, 
simulating closely effusion. 

On the right side, abscess of the liver and hydatid cysts may rise high 
into the pleura and produce dulness and enfeebled breathing. Often in 
these cases there is a friction sound, which should excite suspicion, and 
the upper outline of the dulness is sometimes plainly convex. In a case of 
cancer of the kidney the growth involved the diaphragm very early, and for 
months there were signs of pleurisy before our attention was directed to the 
kidney. In all these instances the exploratory puncture should be made. 

The second question, as to the nature of the fluid, is quickly decided 
by the use of the needle. The persistent fever, the occurrence of sweats, 



676 



DISEASES OF THE RESPIRATORY SYSTEM. 



a leucocytosis, and the increase in the pallor suggest the presence of pus. 
In children the complexion is often sallow and earthy. In protracted cases, 
even in children, when the general symptoms and the appearance of the 
patient has been most strongly suggestive of pus, the syringe has withdrawn 
clear fluid. On the other hand, effusions of short duration may be puru- 
lent, even when the general symptoms do not suggest it. The following 
statement may be made with reference to the prognostic import of the bac- 
teriological examination of the aspirated fluid : The presence of the pneumo- 
coccus is of favorable significance, as such cases usually get well rapidly, 
even with a single aspiration. The streptococcus empyema is the most 
serious form, and even after a free drainage the patient may succumb to a 
general septicaemia. A sterile fluid indicates in a majority of instances a 
tuberculous origin. 

Treatment. — At the onset the severe pain may demand leeches, which 
usually give relief, but a hypodermic of morphia is more effective. The 
Paquelin cautery may be lightly but freely applied. It is well to adminis- 
ter a mercurial or saline purge. Fixing the side by careful strapping with 
long strips of adhesive plaster, which should pass well over the middle line, 
drawn tightly and evenly, gives great relief, and I can corroborate the 
statement of F. T. Roberts as to its efficacy. Cupping, w T et or dry, is now 
seldom employed. Blisters are of no special service in the acute stages, 
although they relieve the pain. The ice-bag may be used as in pneumonia. 
The general treatment at the early stage should be rest in bed and a liquid 
diet. Medicines are rarely required. A Dover's powder may be given at 
night. Mercurials are not indicated. 

When the effusion has taken place, mustard plasters or iodine, pro- 
ducing slight counter-irritation, appear useful, particularly in the later 
stages. The following rational plan is successful in some cases. It is based 
upon the idea that if the blood serum is depleted or if it is kept concen- 
trated, the liquid will be absorbed from the lymph spaces, of which the 
pleura is one, to equalize the loss. To do this the patient should have the 
daily amount of liquid food greatly restricted. If there is no fever, a meat 
diet, with an egg and dry bread and 8 to 10 ounces of liquid in the form of 
milk or water, should be given. Salt articles of food may be used, but I 
do not think it necessary to give, as some do, doses of salt. The second 
element in the treatment is the active depletion of blood serum, which is 
effected in the way introduced by Matthew Hay. Every morning, if the 
patient is robust, otherwise every second morning, from half an ounce to 
an ounce and a half of Epsom salts is given an hour before breakfast, in as 
concentrated a form as is possible. This produces copious liquid discharges. 
I have seen large exudations disappear rapidly when this plan was fol- 
lowed. By acting upon the skin and kidneys, the same end may be ob- 
tained, but with much less certainty. The vapor or hot bath may be 
used and an occasional dose of pilocarpin. Diuretics, such as digitalis, 
squills, and acetate of potash, may sometimes be required. I rarely resort, 
however, to diuretics or diaphoretics in the treatment of pleurisy with effu- 
sion. Iodide of potassium is of doubtful benefit. By some the salicylates 
are believed to be of special efficacy. 



ACUTE PLEURISY. 



677 



Aspiration of the fluid is the most thorough and satisfactory method 
and should be resorted to whenever the effusion becomes large or if it re- 
sists the ordinary methods of treatment. The credit of introducing aspi- 
ration in pleuritic effusions is due to Morrill Wyman, of Cambridge, Mass., 
and Henry I. Bowditch, of Boston. Years prior to Dieulafoy's work, as- 
piration was in constant use at the Massachusetts General Hospital and 
was advocated repeatedly by Bowditch. As the question is one of some 
historical interest, I give Bowditch's conclusions concerning aspiration, 
expressed nearly fifty years ago, and which practically represent the opinion 
of to-day: " (1) The operation is perfectly simple, but slightly painful, and 
can be done with ease upon any patient in however advanced a stage of 
the disease. (2) It should be performed forthwith in all cases in which 
there is complete filling up of one side of the chest. (3) He had deter- 
mined to use it in any case of even moderate effusion lasting more than a 
few weeks and in which there should seem to be a disposition to resist 
ordinary modes of treatment. (4) He urged this practice upon the -profes- 
sion as a very important measure in practical medicine; believing that by 
this method death may frequently be prevented from ensuing either by 
sudden attack of dyspnoea or subsequent phthisis, and, finally, from the 
gradual wearing out of the powers of life or inability to absorb the fluid. 
(5) He believed that this operation would sometimes prevent the occurrence 
of those tedious cases of spontaneous evacuation of purulent fluid and those 
great contractions of the chest which occur after long-continued effusion 
and the subsequent discharge or absorption of a fluid." 

There is scarcely anything to be added to-day to these observations. 
When the fluid reaches to the clavicle the indication for aspiration is im- 
perative, even though the patient be comfortable and present no signs of 
pulmonary distress. The presence of fever is not a contra-indication; in- 
deed, sometimes with serous exudates the temperature falls after aspiration. 

The operation is extremely simple and is practically without risk. The 
spot selected for puncture should be either in the seventh interspace in the 
mid-axilla or at the outer angle of the scapula in the eighth interspace. 
The arm of the patient should be brought forward with the hand on the 
opposite shoulder, so as to widen the interspaces. The needle should be 
thrust in close to the upper margin of the rib, so as to avoid the intercostal 
artery, the wounding of which, however, is an excessively rare accident. 
The fluid should be withdrawn slowly. The amount will depend on the 
size of the exudate. If the fluid reaches to the clavicle a litre or more may 
be withdrawn with safety. In chronic cases of serous pleurisy after re- 
peated tappings S. West has shown the great value of free incision and 
drainage. He has reported cases of recovery after effusions of fifteen and 
eighteen months' standing. 

Symptoms and Accidents during Paracentesis.— Paw is usually com- 
plained of after a certain amount of fluid lias been withdrawn; it is sharp 
and cutting in character. Coughing occurs toward the close, and may be 
severe and paroxysmal. Pneumothorax may follow an exploratory puncture 
with a hypodermic needle; it is rare during aspiration. Subcutaneous em- 
physema may develop from the point of puncture, without the production 



678 



DISEASES OF THE RESPIRATORY SYSTEM. 



of pneumothorax. Albuminous expectoration is a remarkable phenomenon 
described by French writers. It usually develops after the tapping, is asso- 
ciated with dyspnoea, and many prove suddenly fatal. Cerebral symptoms. 
— Faintness is not uncommon. Epileptic .convulsions may occur either 
during the withdrawal or while irrigating the pleura. I have seen but a 
single instance. They are very difficult to explain and are regarded by most 
authors as of reflex origin; and lastly sudden death may occur either from 
syncope or during the convulsions. 

Empyema is really a surgical affection, and I shall make only a few 
general remarks upon its treatment. When it has been determined by 
exploratory puncture that the fluid is purulent, aspiration should not be 
performed, except as preliminary to operation or as a temporary measure. 
Perhaps it is better not to have an exception to this rule, although the 
empyemas of children and the pneumonic empyema occasionally get well 
rapidly after a single tapping. It is sad to think of the number of lives 
which are sacrificed annually by the failure to recognize that empyema 
should be treated as an ordinary abscess, by free incision. The operation 
dates from the time of Hippocrates and is by no means serious. A ma- 
jority of the cases get well, providing that free drainage is obtained, and 
it makes no difference practically what measures are followed so long as 
this indication is met. The good results in any method depend upon 
the thoroughness with which the cavity is drained. Irrigation of the 
cavity is rarely necessary unless the contents are fetid. In the subsequent 
treatment a point of great importance in facilitating the closure of the 
cavity is the distention of the lung on the affected side. This may be 
accomplished by the method advised by Kalston James, which has been 
practised with great success in the surgical wards of the Johns Hopkins 
Hospital. The patient daily, for a certain length of time, increasing gradu- 
ally with the increase of his strength, transfers by air-pressure water from 
one bottle to another. The bottles should be large, holding at least a gallon 
each, and by the arrangement of tubes, as in the WolfFs bottle, an expira- 
tory effort of the patient forces the water from one bottle into the other. 
In this way expansion of the compressed lung is systematically practised. 
The abscess cavity is gradually closed, partly by the falling in of the chest 
wall and partly by the expansion of the lung. In some instances it is 
necessary to resect portions of one or more ribs. 

The physician is often asked, in cases of empyema with emaciation, 
hectic and feeble rapid pulse, whether the patient could stand the opera- 
tion. Even in the most desperate cases the surgeon should never hesitate 
to make a free incision. 



II. CHRONIC PLEURISY. 

This affection occurs in two forms: (1) Chronic pleurisy with effusion, 
in which the disease may set in insidiously or may follow an acute sero- 
fibrinous pleurisy. There are cases in which the liquid persists for months 
or even years without undergoing any special alteration and without becom- 



CHRONIC PLEURISY. 



679 



ing purulent. Such cases have the characters which we have described 
under pleurisy with effusion. (2) Chronic dry pleurisy. The cases are met 
with (a) as a sequence of ordinary pleural effusion. When the exudate is 
absorbed and the layers of the pleura come together there is left between 
them a variable amount of fibrinous material which gradually undergoes 
organization, and is converted into a layer of firm connective tissue. This 
process goes on at the base, and is represented clinically by a slight grade of 
flattening, deficient expansion, defective resonance on percussion, and en- 
feebled breathing. After recovery from empyema the flattening and re- 
traction may be still more marked. In both cases it is a condition which 
can be greatly benefited by pulmonary gymnastics. In these firm, fibrous 
membranes calcification may occur, particularly after empyema. It is 
not very uncommon to find between the false membranes a small pocket 
of fluid forming a sort of pleural cyst. In the great majority of these 
cases the condition is one which need not cause anxiety. There may be 
an occasional dragging pain at the base of the lung or a stitch in the side, 
but patients may remain in perfectly good health for years. The most 
advanced grade of this secondary dry pleurisy is seen in those cases of em- 
pyema which have been left to themselves and have perforated and ulti- 
mately healed by a gradual absorption or discharge of the pus, with retrac- 
tion of the side of the chest and permanent carnification of the lung. 
Traumatic lesions, such as gunshot wounds, may be followed by an identical 
condition. Post mortem, it is quite impossible to separate the layers of the 
pleura, which are greatly thickened, particularly at the base, and surround 
a compressed, airless, fibroid lung. Bronchiectasis may gradually develop, 
and in one remarkable case which I have seen on several occasions with 
Dr. Blackader, of Montreal, not only on the affected side, but also in the 
lower lobe of the other lung. 

('&) Primitive dry pleurisy. This condition may directly follow the 
acute plastic pleurisy already described; but it may set in without any 
acute symptoms whatever, and the patient's attention may be called to it 
by feeling the pleural friction. A constant effect of this primitive dry 
pleurisy is the adhesion of the layers. This is probably an invariable result, 
whether the pleurisy is primary or secondary. The organization of the thin 
layer of exudation in a pneumonia will unite the two surfaces by delicate 
bands. Pleural adhesions are extremely common, and it is rare to examine 
a body entirely free from them. They may be limited in extent or univer- 
sal. Thin fibrous adhesions do not produce any alteration in the percussion 
characters, and, if limited, there is no special change heard on ausculta- 
tion. When, however, there is general synechia on both sides the expansile 
movement of the lung is considerably impaired. We should naturally 
think that universal adhesions would interfere materially with the func- 
tion of the lungs, but practically we see many instances in which there 
has not been the slightest disturbance. The physical signs of total adhe- 
sion are by no means constant. It has been stated that there is a marked 
disproportion between the degree of expansion of the chest walls and the 
intensity of the vesicular murmur, but the latter is a very variable factor, 
and under perfectly normal conditions the breath-sounds, with very full 



680 



DISEASES OF THE RESPIRATORY SYSTEM. 



chest expansion, may be extremely feeble. The diaphragm phenomenon — 
Litten's sign — is absent. 

Is there a primitive dry pleurisy which gradually leads to great thick- 
ening of the membranes, and which ultimately may invade the lung and 
induce cirrhotic change? Upon this question neither pathologists nor 
clinicians agree. I think that Sir Andrew Clark, in his Lumleian lectures 
at the Eoyal College of Physicians (1885), has made good his claim that 
such a disease does exist. Clinically the cases are of great interest, and 
should, I think, be separated, on the one hand, from the condition which 
follows a healed empyema or old pleurisy with effusion, and, on the other, 
from the rare instances of primitive cirrhosis of the lung. However, in all 
three states there may ultimately be an almost identical clinical picture. 
Anatomically in these pleuritic cases the pleura, particularly that surround- 
ing the lower lobe, sometimes the entire membrane, is thicker '/d, the two 
layers are intimately united, and fibrinous bands passing from the pleura 
traverse the lung tissue, sometimes dividing it in a remarkable way into 
sections. The bronchi may present marked dilatations, though this is 
not always the case, and the lung tissue is more or less sclerosed. The 
cases belong to the group of chronic pneumonias called by Charcot pleu- 
rogenous. 

Lastly, there is a primitive dry pleurisy of tuberculous origin. In it 
both parietal and costal layers are greatly thickened — perhaps from 2 to 
3 mm. each — and present firm fibroid, caseous masses and small tubercles, 
while uniting these two greatly thickened layers is a reddish-gray fibroid 
tissue, sometimes infiltrated with serum. This may be a local process con- 
fined to one pleura, or it may be in both. These cases are sometimes associ- 
ated with a similar condition in the pericardium and peritonaeum. 

Occasionally remarkable vaso-motor phenomena occur in chronic pleu- 
risy, whether simple or in connection with tuberculosis of an apex. Flush- 
ing or sweating of one cheek or dilatation of the pupil are the common 
manifestations. They appear to be due to involvement of the first thoracic 
ganglion at the top of the pleural cavity. 



III. HYDROTHORAX. 

Hydrothorax is a transudation of simple non-inflammatory fluid into 
the pleural cavities, and occurs as a secondary process in many affections. 
The fluid is clear, without any flocculi of fibrin, and the membranes are 
smooth. It is met with more particularly in connection with general 
dropsy, either renal, cardiac, or hamric. . It may, however, occur alone, or 
with only slight oedema of the feet. A child was admitted to the Mont- 
real General Hospital with urgent dyspnoea and cyanosis, and died the 
night after admission. She had extensive bilateral hydrothorax, which 
had come on early in the nephritis of scarlet fever. In renal disease hydro- 
thorax is almost always bilateral, but in heart affections one pleura is more 
commonly involved. The physical signs are those of pleural effusion, but 
the exudation is rarely excessive. In kidney and heart-disease, even when 



PNEUMOTHORAX. 



681 



there is no general dropsy, the occurrence of dyspnoea should at once 
direct attention to the pleura, since many patients are carried off by a 
rapid effusion. Post-mortem records show the frequency with which this 
condition is overlooked. The saline purges will in many cases rapidly 
reduce the effusion, but, if necessary, aspiration should repeatedly be 
practised. 



IV. PNEUMOTHORAX {Hydro- Pneumothorax and Pyo-Pneumothorax). 

Air alone in the pleural cavity, to which the term pneumothorax is 
strictly applicable, is an extremely rare condition. It is almost invariably 
associated with a serous fluid — hydro-pneumothorax, or with pus — pyo- 
pneumothorax. 

Etiology. — There exists normally within the pleural cavity of an adult 
a negative pressure of several millimetres of mercury, due to the recoil of 
the distended, perfectly elastic, lung. Hence through any opening con- 
necting the pleural cavity with the external air we should expect air to 
rush in until this negative pressure is relieved. To explain the absence of 
pneumothorax in a few cases in which it would be expected, S. West has 
assumed the existence of a cohesion between the pleurae which overcomes 
the tendency of the chest to this condition, but this force has not as yet 
been satisfactorily demonstrated. 

In a case of pneumothorax, if the opening causing it remain patent, 
the intrathoracic pressure will be that of the atmosphere, the lung will be 
found to have collapsed by virtue of its own elastic tension, the intercostal 
grooves obliterated, the heart displaced to the other side, and the diaphragm 
lower than normal, because the negative pressure by reason of which these 
organs are retained in their ordinary position has been relieved. If the 
opening becomes closed the intrathoracic pressure may rise above the at- 
mospheric and the above-mentioned displacements be much increased. 
Some of the reasons for this rise of pressure are, the valvular action of the 
opening during violent expiratory efforts, the rise of temperature of the im- 
prisoned gas, and the compression of the air by the usual effusion into the 
cavity. 

Pneumothorax arises: (1) In perforating wounds of the chest, in which 
case it is sometimes associated with extensive cutaneous emphysema. It 
has followed exploratory puncture. Herman Biggs has reported two cases 
and I have seen it twice. Pneumothorax rarely follows fracture of the rib, 
even though the lung may be torn. (2) In perforation of the pleura- 
through the diaphragm, usually by malignant disease of the stomach or 
colon. The pleura may also be perforated in cases of cancer of the oesoph- 
agus. (3) When the lung is perforated. This is by far the most com- 
mon cause, and may occur: (a) In a normal lung from rupture of the 
air-vesicles during straining or even when at rest. Special attention has 
been called to this accident by S. West and De IT. Hall. The air may bo 
absorbed and no ill effect follows. It does not necessarily excite pleurisy, 
as pointed out many years ago by Gairdner, but inflammation and effusion 



682 



DISEASES OF THE KESPIRATORY SYSTEM. 



are the usual result. In a recent case the condition developed as the pa- 
tient was going down-stairs; no effusion followed; he did not react to 
tuberculin, (b) From perforation due to local disease of the lung, either 
the softening of a caseous focus or the breaking of a tuberculous cavity. 
According to S. West, 90 per cent of all the cases are due to this cause. 
Less common are the cases due to septic broncho-pneumonia and to gan- 
grene. A rare cause is the breaking of a hemorrhagic infarct in chronic 
heart-disease, of which I met an instance a few years ago. (c) Perfora- 
tion of the lung from the pleura, which arises in certain cases of empyema 
and produces a pleuro-bronchial fistula. (d) Spontaneously, by the de- 
velopment in pleural exudates of the gas bacillus (B. aerogenes capsulatus 
Welch). 

Pneumothorax occurs chiefly in adults, though cases are met with in 
very young children. It is more frequent in males than in females. 

Morbid Anatomy. — If a trocar or blow-pipe is inserted between 
the ribs, there may be a jet of air of sufficient strength to blow out a 
lighted match. On opening the thorax the mediastinum and pericardium 
are seen to be pushed, or rather, as Douglas Powell pointed out, drawn 
over to the opposite side; but, as before mentioned, the heart is not 
rotated, and the relation of its parts is maintained much as in the normal 
condition. A serous or purulent fluid is usually present, and the mem- 
branes are inflamed. The cause of the pneumothorax can usually be 
found without difficulty. In the great majority of instances it is the 
perforation of a tuberculous cavity or a breaking of a superficial caseous 
focus. The orifice of rupture may be extremely small. In chronic cases 
there may be a fistula of considerable size communicating with the bron- 
chi. The lung is usually compressed and carnified. 

Symptoms. — The onset is usually sudden and characterized by severe 
pain in the side, urgent dyspnoea, and signs of general distress, as indicated 
by slight liviclity and a very rapid and feeble pulse. There may, however, 
be no urgent symptoms, particularly in cases of long-standing phthisis. 
On more than one occasion I have found, post mortem, a pneumothorax 
which was unsuspected during life. West states that even in healthy 
adults this latent pneumothorax may occasionally occur. 

A remarkable recurrent variety has been described by S. West, Good- 
hart, and Furney. In Goodhart's case the pneumothorax developed first 
in one side and then in the other. 

The physical signs are very distinctive. Inspection shows marked en- 
largement of the affected side with immobility. The heart impulse is 
•usually much displaced. On palpation the fremitus is greatly diminished 
or more commonly abolished. On percussion the resonance may be tym- 
panitic or even have an amphoric quality. This, however, is not always 
the case. It may be a flat tympany, resembling Skoda's resonance. In 
some instances it may be a full, hyperresonant note, like emphysema: 
while in others — and this is very deceptive — there is dulness. These 
extreme variations depend doubtless upon the degree of intrapleural ten- 
sion. On several occasions I have known an error in diagnosis to result 
from ignorance of the fact that, in certain instances, the percussion note 



PNEUMOTHORAX. 683 

may be " muffled, toneless, almost dull " (Walshe). There is usually dul- 
ness at the base from effused fluid, which can readily be made to change 
the level by altering the position of the patient. Movable dulness can 
be obtained much more readily in pneumothorax than in a simple pleu- 
risy. On auscultation the breath-sounds are suppressed. Sometimes 
there is only a distant feeble inspiratory murmur of marked amphoric 
quality. The contrast between the loud exaggerated breath-sounds on 
the normal side and the absence of the breath-sounds on the other is 
very suggestive. The rales have a peculiar metallic quality, and on 
coughing or deep inspiration there may be what Laennec termed the 
metallic tinkling. The voice, too, has a curious metallic echo. What is 
sometimes called the coin-sound, termed by Trousseau the bruit oVairain, 
is very characteristic. To obtain it the auscultator should place one ear 
on the back of the chest wall while the assistant taps one coin on another 
on the front of the chest. The metallic echoing sound which is produced 
in this way is one of the most constant and characteristic signs of pneumo- 
thorax. And, lastly, the Hippocratic succussion may be obtained when 
the auscultatory head is placed upon the chest while the patient's body is 
shaken. A splashing sound is produced, which may be audible at a dis- 
tance. A patient may himself notice it in making abrupt changes in 
posture. Of other symptoms displacement of organs is most constant. 
As already mentioned, the heart may be drawn over to the opposite side, 
and the liver greatly displaced, so that its upper surface is below the level 
of the costal margin, a degree of dislocation never seen in simple effusion. 

The diagnosis of pneumothorax rarely offers any difficulty, as the signs 
are very characteristic. In cases in which the percussion note is dull the 
condition may be mistaken for effusion. I made this mistake in a case of 
pulsating pleurisy, in which the pneumothorax followed heavy lifting, and 
it was not until several days later, after some of the fluid had been with- 
drawn, that a tympanitic note developed. Diaphragmatic hernia follow- 
ing a crush or other accident may closely simulate pneumothorax. 

In cases of very large phthisical cavities with tympanitic percussion 
resonance and rales of an amphoric, metallic quality, the question of pneu- 
mothorax is sometimes raised. In those rare instances of total excava- 
tion of one lung the amphoric and metallic phenomena may be most in- 
tense, but the absence of dislocation of the organs, of the succussion splash, 
and of the coin-sound suffice to differentiate this condition. While this is 
true in the great majority of cases, I have recently heard the bruit d'airain 
over large cavities of the right upper lobe. The condition of pyopneu- 
mothorax subphrenicus may simulate closely true pneumothorax. 

The prognosis in cases of pneumothorax depends largely upon the cause. 
S. West gives a mortality of 70 per cent. The tuberculous cases usually 
die within a few weeks. Of 39 cases, 29 died within a fortnight (West); 
10 patients died on the first day, 2 within twenty and thirty minutes re- 
spectively of the attack. Pneumothorax developing in a healthy individual 
often ends in recovery. There are tuberculous cases in which the pneu- 
mothorax, if occurring early, seems to arrest the progress of the tubercu- 
losis. This appeared to be the case in a man with chronic pneumothorax 



4 

684 DISEASES OF THE RESPIRATORY SYSTEM. 

who was under my care in Philadelphia for between three and four years. 
It may be a chronic condition, as in the case just mentioned, and a fair 
measure of health may be enjoyed. 

Treatment. — Practically these cases should be dealt with as ordinary 
pleurisy with effusion. Of course, when pneumothorax develops in ad- 
vanced phthisis the indication is to relieve the pain and distress either by 
morphia or chloroform; but in cases which develop early the fluid should 
be withdrawn by aspiration, or, if purulent, permanent drainage should be 
obtained. Even when the condition has seemed to be most desperate I 
have known recovery to take place after thorough drainage of the sac. 
Portions of ribs may have to be excised, and during convalescence it is 
Avell for the patient to practise expansion of the lung in the manner 
already mentioned. There are cases of pneumothorax in phthisis in which 
the general condition is so good and the inconvenience so slight that to 
let well enough alone seems the best course. ' In such an occasional as- 
piration may be performed if the fluid increases. In some of the in- 
stances the mere tapping of the chest with a fine needle, so as to allow 
the escape of some of the air, seems to give relief by reducing the intra- 
thoracic pressure. Good results are stated to have followed the method 
introduced by Potain, of replacing the air and fluid within the thorax by 
sterilized air. 



V. AFFECTIONS OF THE MEDIASTINUM. 

(1) Simple Lymphadenitis. — In all inflammatory affections of the 
bronchi and of the lungs the groups of lymph-glands in the mediastinum 
become swollen. In the bronchitis of measles, for example, and in simple 
broncho-pneumonia the bronchial glands are large and infiltrated, the 
tissue is engorged and cedematous, sometimes intensely hyperemia Much 
stress has been laid by some writers on this enlargement of the glands in 
the posterior mediastinum, and De Mussy held that it was an important 
factor in inducing paroxysms of whooping-cough. They may attain a 
size sufficient to induce dulness beneath the manubrium and in the upper 
part of the interscapular regions behind, though this is often difficult to 
determine. In reality the glands lie chiefly upon the spine, and unless 
those which are deep in the root of the lung are large enough to induce 
compression of the adjacent lung tissue, I doubt if the ordinary bronchial 
adenopathy ever can be determined by percussion in the upper interscapu- 
lar region. I have never met with an instance in which the compression 
of either bronchus seemed to have resulted from the glands, however large. 
Tuberculous affection of these glands has already been considered. 

(2) Suppurative Lymphadenitis. — Occasionally abscess in the bronchial 
or tracheal lymph-glands is found. It may follow the simple adenitis, but 
is most frequently associated with the presence of tubercle. The liquid 
portion may gradually become absorbed and the inspissated contents un- 
dergo calcification. Serious accidents occasionally occur, as perforation 
into the oesophagus or into a bronchus, or in rare instances, as in the case 



AFFECTIONS OF THE MEDIASTINUM. 



6S5 



reported by Sidney Phillips, perforation of the aorta, as well as a bronchus, 
which, it is remarkable to say, did not prove fatal rapidly, but caused re- 
peated attacks of haemoptysis during a period of sixteen months. 

(3) Tumors ; Cancer and Sarcoma. — In Hare's elaborate study of 520 
cases of disease of the mediastinum * there were 134 cases of cancer, 98 
cases of sarcoma, 21 cases of lymphoma, 7 cases of fibroma, 11 cases of 
dermoid cysts, 8 cases of hydatid cysts, and instances of lipoma, gumma, 
and enchondroma. -From this we see that cancer is the most common 
form of growth. The tumor occurred in the anterior mediastinum alone 
in -18 of the cases of cancer and in 33 of the cases of sarcoma. There are 
three chief points of origin, the thymus, the lymph-glands, and the pleura 
and lung. Sarcoma is more frequently primary than cancer. Males are 
more frequently affected than females. The age of onset is most com- 
monly between thirty and forty. 

Symptoms. — The signs of mediastinal tumor are those of intra- 
thoracic pressure. Dyspnoea is one of the earliest and most constant 
symptoms, and may be due either to pressure on the trachea or on the 
recurrent laryngeal nerves. It may indeed be cardiac, due to pressure 
upon the heart or its vessels. In a few cases it results from the pleural 
effusion which so frequently accompanies intrathoracic growths. Asso- 
ciated with the dyspnoea is a cough, often severe and paroxysmal in char- 
acter, with the brazen quality of the so-called aneurismal cough when a 
recurrent nerve is involved. The voice may also be affected from a simi- 
lar cause. Pressure on the vessels is common. The superior \ r ena cava 
may be compressed and obliterated, and when the process goes on slowly 
the collateral circulation may be completely effected. Less commonly the 
inferior vena cava or one or other of the subclavian veins is compressed. 
The arteries are much more rarely obstructed. It is remarkable how little 
the aorta may be involved, though entirely surrounded by a sarcomatous 
or cancerous mass. There may be dysphagia, due to compression of the 
oesophagus. In rare instances there are pupillary changes, either dilatation 
or contraction, due to involvement of the sympathetic. 

Physical Signs. — On inspection there may be orthopncea and marked 
cyanosis of the upper part of the body. In such instances, if of long 
duration, there are signs of collateral circulation and the superficial mam- 
mary and epigastric veins are enlarged. In these cases of chronic obstruc- 
tion the finger-tips may be clubbed. There may be bulging of the ster- 
num or the tumor may erode the bone and form a prominent subcutaneous 
growth. The rapidly growing lymphoid tumors more commonly than 
others perforate the chest wall. In 4 of 13 cases of Hodgkin's disease, 
there was mediastinal growth, and in 3 instances the sternum was eroded 
and perforated. The perforation may be on one side of the breast-bone. 
The projecting tumor may pulsate; the heart may be dislocated and its 
impulse much out of place. Contraction of one side of the thorax has been 
noted in a few instances. On palpation the fremitus is absent wherever 
the tumor reaches the chest wall. If pulsating, it rarely has the forcible, 



* Fothergillian Prize Essay of the Medical Society of London, Philadelphia, 1889. 



686 



DISEASES OF THE RESPIRATORY SYSTEM. 



heaving impulse of an aneurismal sac. On auscultation there is usually 
silence over the dull region. The heart-sounds are not transmitted and 
the respiratory murmur is feeble or inaudible, rarely bronchial. Yocal 
resonance is, as a rule, absent. Signs of pleural effusion occur in a great 
many instances of mediastinal growth, and in doubtful cases the aspirator 
needle should be used. 

Tumors of the anterior mediastinum originate usually in the thymus; 
the sternum is pushed forward and often eroded. The growth may be 
felt in the suprasternal fossa; the cervical glands are usually involved. 
The pressure symptoms are chiefly upon the venous trunks. Dyspnoea is 
a prominent feature. 

Intrathoracic tumors in the middle and posterior mediastinum originate 
most commonly in the lymph-glands. The symptoms are out of all pro- 
portion to the physical signs; there is urgent dyspnoea and cough, which 
is sometimes loud and ringing. The pressure symptoms are chiefly upon 
the gullet, the recurrent laryngeal, and sometimes upon the azygos vein. 

In a third group, tumors originating in the pleura and the lung, the 
pressure symptoms are not so marked. Pleural exudate is very much 
more common; the patient becomes anaemic and emaciation is rapid. 
There may be secondary involvement of the lymph-glands in the neck. 
For a discussion of the symptomatology of these different groups, see 
Pepper and Stengel, Transactions of the Association of American Physi- 
cians, vol. x. 

The diagnosis of mediastinal tumor from aneurism is sometimes ex- 
tremely difficult. An interesting case reported and figured by Sokolosski, 
in Bd. 19 of the Deutsches Archiv fiir klinische Medicin, in which 
Oppolzer diagnosed aneurism and Skoda mediastinal tumor, illustrates 
how in some instances the most skilful of observers may be unable to 
agree. Scarcely a sign is found in aneurism which may not be duplicated 
in mediastinal tumor. This is not strange, since the symptoms in both 
are largely due to pressure. The time element is important. If a case 
has persisted for more than eighteen months the disease is probably aneu- 
rism. There are, however, exceptions to this. By far the most valuable 
sign of aneurism is the diastolic shock so often to be felt, and in a majority 
of cases to be heard, over the sac. This is rarely, if ever, present in medias- 
tinal growths, even when they perforate the sternum and have communi- 
cated pulsation. Tracheal tugging is rarely present in tumor. Another 
point of importance is that a tumor, advancing from the mediastinum, 
eroding the sternum and appearing externally, if aneurismal, has forcible, 
heaving, and distinctly expansile pulsations. The radiating pain in the 
back and arms and neck is rather in favor of aneurism, as is also a bene- 
ficial influence on it of iodide of potassium. 

The frequency of pleural effusion in connection with mediastinal tumor 
is to be constantly borne in mind. It may give curiously complex char- 
acters to the physical signs — characters which are profoundly modified 
after aspiration of the liquid. 

(4) Abscess of the Mediastinum. — Hare collected 115 cases of medi- 
astinal abscess, in 77 of which there were details sufficient to permit the 



AFFECTIONS OF THE MEDIASTINUM. 



687 



analysis. Of these cases the great majority occurred in males. Forty-four 
were instances of acute abscess. The anterior mediastinum is most com- 
monly the seat of the suppuration. The cases are most frequently associated 
with trauma. Some have followed erysipelas or occurred in association 
with eruptive fevers. Many cases, particularly the chronic abscesses, are 
of tuberculous origin. Of symptoms, pain behind the sternum is the most 
common. It may be of a throbbing character, and in the acute cases is 
associated with fever, sometimes with chills and sweats. If the abscess is 
large there may be dyspnoea. The pus may burrow into the abdomen, 
perforate through an intercostal space, or it may erode the sternum. In- 
stances are on record in which the abscess has discharged into the trachea 
or oesophagus. In many cases, particularly of chronic abscess, the pus 
becomes inspissated and produces no ill effect. The physical signs may 
be very indefinite. A pulsating and fluctuating tumor may appear at the 
border of the sternum or at the sternal notch. The absence of bruit, of 
the diastolic shock, and of the expansile pulsation usually enables a cor- 
rect diagnosis to be made. When in doubt a fine hypodermic needle may 
be inserted. 

(5) Indurative Mediastino-Pericarditis. — Harris has recently reviewed 
the subject. In one form there is adherent pericardium and great increase 
in the fibrous tissues of the mediastinum; in another there is adherent peri- 
cardium with union to surrounding parts, but very little mediastinitis; in 
a third the pericardium may be uninvolved. The disease is rare; of 
22 cases 17 were in males; only 2 were above thirty years of age. The 
symptoms are essentially those of that form of adhesive pericardium which 
is associated with great hypertrophy and dilatation of the heart, and in 
which the patients present a picture of cyanosis, dyspnoea, anasarca, etc. 
The pulsus paradoxus, described by Kussmaul, is not distinctive. Occa- 
sionally there is also a proliferative peritonitis. Mediastinal friction is 
sometimes heard in patients with adhesive mediastino-pericarditis — dry, 
coarse, crackling rales heard along the sternum, particularly when the 
arms are raised. 

(6) Miscellaneous Affections. — In Hare's monograph there were 7 in- 
stances of fibroma, 11 cases of dermoid cyst, 8 cases of hydatid cyst, and 
cases of lipoma and gumma. 

(7) Emphysema of the Mediastinum.— Air in the cellular tissues of the 
mediastinum is met with in cases of trauma, and occasionally in fatal cases 
of diphtheria and in whooping-cough. It may extend to the subcutaneous 
tissues. Champneys has called attention to its frequency after tracheotomy, 
in which, he says, the conditions favoring the production are division of the 
deep fascia, obstruction in the air-passages, and inspiratory efforts. The 
deep fascia, he says, should not be raised from the trachea. It is often 
associated with pneumothorax. The condition seems by no means uncom- 
mon. Angel Money found it in 16 of 28 cases of tracheotomy, and in 2 
of these pneumothorax also was present. 



4a 



SECTION VII. 



DISEASES OF THE OIECULATOET SYSTEM. 



I. DISEASES OF THE PEKICAKDIUM. 
I. PERICARDITIS. 

Pericarditis is the result of infective processes, primary or secondary, 
or arises by extension of inflammation from contiguous organs. 

Etiology. — Primary, so-called idiopathic, inflammation is rare; but 
cases occur, chiefly in children, in whom there is no evidence of rheuma- 
tism or of any local or general disease. Certain of these cases are tuber- 
culous. 

Pericarditis from injury usually comes under the care of the surgeon 
in connection with the primary wound. The trauma may be from within, 
due to the passage of a foreign body — a needle, a pin, or a bone — through 
the oesophagus — a variety exceedingly common in cows and horses. 

As a secondary process pericarditis occurs: (a) Most frequently in con- 
nection with rheumatism. The percentage given by different authors 
ranges from thirty to seventy. The articular trouble may be slight or, 
indeed, the disease may be associated with acute tonsillitis in rheumatic 
subjects. Certain of the so-called idiopathic cases have their origin in an 
acute tonsillitis. The pericarditis may precede the arthritis, (b) In septic 
processes; in the acute necrosis of bone and in puerperal fever it is not un- 
common, (c) In tuberculosis, in which the disease may be primary or part 
of a general involvement of the serous sacs or associated with extensive 
pulmonary disease, (d) In the eruptive fevers. Not infrequent after 
scarlatina; it is rare in measles, small-pox, typhoid fever, and diphtheria. 
In pneumonia it is not uncommon. Pericarditis sometimes complicates 
chorea; it was present in 19 of 73 autopsies which I collected; in only 8 of 
these was arthritis present, (e) In certain altered conditions of the system, 
in which gout takes the first place. Pericarditis in chronic Bright's dis- 
ease — the pericardite brightique of the French — is one of the most impor- 
tant forms in persons over fifty years of age, and is most frequent in the 
slow interstitial variety. As a terminal infection pericarditis is a 
very common event in chronic illnesses of all sorts. It is usually over- 
looked, hence the incidence of acute pericarditis in the post-mortem room 
is greatly in excess of that of the wards. Pericarditis has been met with 
also in scurvy and diabetes. 
688 



PERICARDITIS. 



689 



Pericarditis hy Extension. — In pleuropneumonia it forms a serious com- 
plication, and was present in 5 cases of 100 post mortems in this disease 
which I made at the Montreal General Hospital. It is most often met with 
in the pleuro-pneumonia of children and of alcoholics. With simple pleu- 
risy it is rare. In ulcerative endocarditis, purulent myocarditis, and in 
aneurism of the aorta pericarditis is occasionally found. It may also follow 
extension of the disease from the bronchial glands, the ribs, sternum, verte- 
brae, and even from the abdominal viscera. The ordinary pus cocci, the 
pneumococcus, and the tubercle bacillus are the chief organisms met with 
in acute pericarditis. 

Pericarditis occurs at all ages. Cases have been reported in the foetus. 
In the new-born it may result from septic infection through the navel. 
Throughout childhood the incidence of rheumatism and scarlet fever makes 
it a frequent affection, whereas late in life it is most often associated with 
tuberculosis, Bright's disease, and gout. Males are somewhat more fre- 
quently attacked than females. Climatic and seasonal influences have been 
mentioned by some writers. The so-called epidemics of pericarditis have 
been outbreaks of pneumonia with this as a frequent complication. 

Of 100 consecutive cases at the Boston City Hospital analyzed by Sears, 
in 54 the exudate was dry, in 41 serous, in 4 hsemorrhagic, and in 5 puru- 
lent. Thirty-four cases &howed signs of old valvular disease; rheumatism 
was a factor in 51; pneumonia in 18; and in 7 chronic nephritis. Of the 
100 cases 43 died. 

Anatomically as well as clinically the disease may be considered under 
the following divisions: 

1. Acute, plastic, or dry pericarditis. 

2. Pericarditis with effusion — sero-fibrinous, hsemorrhagic, or purulent. 

3. Chronic adhesive pericarditis (adherent pericardium). 

Acute Plastic Pericarditis. — This, the most common form, occurs usu- 
ally as a secondary process, and is distinguished by the small amount of 
fluid exudation, which does not, as in the next variety, give special charac- 
ters to the disease. It is a benign form and never of itself proves fatal. 

Anatomically it may be partial or general. In the mildest grades the 
serous membrane looks lustreless and roughened. This is due to the pres- 
ence of a thin fibrinous sheeting, which can be lifted with the knife, showing 
the membrane beneath to be injected or in places ecchymotic. As the 
fibrinous sheeting increases in thickness the constant movement of the 
adjacent surfaces gives to it sometimes a ridge-like, at others a honey- 
combed appearance. With more abundant fibrinous exudation the mem- 
branes present an appearance resembling buttered surfaces which have been 
drawn apart. The fibrin is in long shreds, and the heart presents a curiously 
shaggy appearance — the so-called hairy heart of old writers— cor villosum. 

In mild grades the subjacent muscle looks normal; but in the more 
prolonged and severe cases there is myocarditis, and for 2 or 3 mm. be- 
neath the visceral layer the muscle presents a pale, turbid appearance. 
Many of these acute cases are tuberculous; covered by the layers of lymph 
the granulations are easily overlooked in a superficial examination. 



690 



DISEASES OF THE CIRCULATORY SYSTEM. 



Slight fluid exudation is invariably present, entangled in the meshes 
of fibrin, but there may be very thick fibrinous layers without much serous 
effusion. 

Symptoms. — The majority of cases of simple plastic pericarditis, like 
those of simple endocarditis, present no symptoms, and unless sought for 
there are no objective signs indicating its existence. In the post-mortem 
room it is not uncommon to find it in cases in which its presence has been 
unsuspected during life. 

Pain is a variable symptom, not usually intense, and in this form rarely 
excited by pressure. . It is more marked in the early stage, and may be 
referred either to the prsecordia or to the region of the xiphoid cartilage. 
Instances are recorded of pain of an aggravated and most distressing char- 
acter resembling angina. Fever is usually present, but it is not always easy 
to say how much depends upon the primary febrile affection, and how much 
upon the pericarditis. It is as a rule not high, rarely exceeding 102.5°. 
In rheumatic cases hyperpyrexia has been observed. 

Physical Signs. — Inspection is negative; palpation may reveal the pres- 
ence of a distinct fremitus caused by the rubbing of the roughened peri- 
cardial surfaces. This is usually best marked over the right ventricle. It 
is not always to be felt, even when the friction sound on auscultation is 
loud and clear. Auscultation: The friction sound, due to the movement 
of the pericardial surfaces upon each other, is one of the most distinctive 
of physical signs. It is double, corresponding to the systole and diastole; 
but the synchronism with the heart-sounds is not accurate, and the to-and- 
fro murmur usually outlasts the time occupied by the first and second 
sound. In rare instances the friction is single; more frequently it ap- 
pears to be triple in character — a sort of canter rhythm. The sounds have 
a peculiar rubbing, grating quality, characteristic when once recognized, 
and rarely simulated by endocardial murmurs. Sometimes instead of 
grating there is a creaking quality— the bruit de cuir neuf — the new-leather 
murmur of the French. The pericardial friction appears superficial, very 
close to the ear, and is usually intensified by pressure with the stethoscope. 
It is best heard over the right ventricle, the part of the heart which is most 
closely in contact with the front of the chest — that is, in the fourth and 
fifth interspaces and adjacent portions of the sternum. There are instances 
in which the friction is most marked at the base, over the aorta, and at 
the superior reflection of the pericardium. Occasionally it is best heard 
at the apex. It may be limited and heard over a very narrow area, or it 
may be transmitted up and down the sternum. There are, however, no 
definite lines of transmission as in the endocardial murmur. An important 
point is the variability of the sounds, both in position and quality; they may 
be heard at one visit and not at another. The maximum of intensity will 
be found to vary with position. 

Diagnosis. — There is rarely any difficulty in determining the pres- 
ence of a dry pericarditis, for the friction sounds are distinctive. The 
double murmur of aortic incompetency may simulate closely the to-and- 
fro pericardial rub. I recall one instance at least in which this mistake was 
made. The constant character of the aortic murmur, the direction of trans- 



PERICARDITIS. 



691 



mission, the phenomena in the arteries, and the associated conditions of 
the disease should be sufficient to prevent this error. 

I have never known an instance in which pericarditis was mistaken for 
acute endocarditis, though writers refer to such, and give the differential 
diagnosis in the two affections. The only possible mistake could be made 
in those rare instances of single soft, systolic, pericardial friction. 

Pleuro-pericardial friction is very common, and may be associated with 
endo-pericarditis, particularly in cases of pleuro-pneumonia. It is fre- 
quent, too, in phthisis. It is best heard over the left border of the heart, 
and is much affected by the respiratory movement. Holding the breath 
or taking a deep inspiration may annihilate it. The rhythm is not the sim- 
ple to-and-fro diastolic and systolic, but the respiratory rhythm is super- 
added, usually intensifying the murmur during expiration and lessening 
it on inspiration. In phthisis there are instances in which, with the fric- 
tion, a loud systolic click is heard, due to the compression of a thin layer 
of lung and the expulsion of a bubble of air from a small softening focus 
or from a bronchus. 

And, lastly, it is not very uncommon, in the region of the apex beat, to 
hear a series of fine crepitant sounds, systolic in time, often very distinct, 
suggestive of pericardial adhesions, but heard too frequently for this cause. 

Course and Termination. — Simple fibrinous pericarditis never kills, but 
it occurs so often in connection with serious affections that we have fre- 
quent opportunities to see all stages of its progress. In the majority of 
cases the inflammation subsides and the thin fibrinous lamina? gradually 
become converted into connective tissue, which unites the pericardial leaves 
firmly together. In other instances the inflammation progresses, with in- 
crease of the exudation, and the condition is changed from a " dry " to a 
" moist " pericarditis, or the pericarditis with effusion. 

In a few instances — probably always tuberculous — the simple plastic 
pericarditis becomes chronic, and great thickening of both visceral and 
parietal layers is gradually induced. 

Pericarditis with Effusion. — Though commonly a direct sequence of 
the dry or plastic pericarditis, of which it is sometimes called the second 
stage, this form presents special features and deserves separate considera- 
tion. It is found most frequently in association with acute rheumatism, 
tuberculosis, and septicaemia, and sets in usually with the symptoms above 
described, namely, precordial pain, with slight fever or a distinct chill. 

In children the disease may, like pleurisy, come on without local symp- 
toms, and, after a week or two of failing health, slight fever, shortness of 
breath, and increasing pallor, the physician may find, to his astonishment, 
signs of most extensive pericardial effusion. These latent cases are often 
tuberculous. W. Ewart has called special attention to latent and ephemeral 
pericardial effusions, which lie thinks are often of short duration and of 
moderate size, with an absence of the painful features of pericarditis. The 
effusion may be sero-fibrinous, hemorrhagic, or purulent. The amount 
varies from 200 or 300 cc. to 2 litres. In the cases of sero-fibrinous exuda- 
tion the pericardial membranes are covered with thick, creamy fibrin, which 



692 



DISEASES OF THE CIRCULATORY SYSTEM. 



may be in ridges or honeycombed, or may present long, villous extensions. 
The parietal layer may be several millimetres in thickness and may form 
a firm, leathery membrane. The hamiorrhagic exudation is usually associ- 
ated with tuberculous, or with cancerous pericarditis, or with the disease 
in the aged. The lymph is less abundant, but both surfaces are injected 
and often show numerous haemorrhages. Thick, curdy masses of lymph 
are usually found in the dependent part of the sac. In the purulent effu- 
sion the fluid has a creamy consistency, particularly in tuberculosis. In 
many cases the effusion is really sero-purulent, a thin, turbid exudation con- 
taining flocculi of fibrin. 

The pericardial layers are greatly thickened and covered with fibrin. 
When the fluid is pus, they present a grayish, rough, granular surface. 
Sometimes there are distinct erosions on the visceral membrane. The 
heart muscle in these cases becomes involved to a greater or less extent, 
and on section, the tissue, for a depth of from 2 to 3 mm., is pale and 
turbid, and shows evidence of fatty and granular change. Endocarditis 
coexists frequently, but rarely results from the extension of the inflamma- 
tion through the wall of the heart. 

Symptoms. — Even with copious effusion the onset and course may 
be so insidious that no suspicion of the true nature of the disease is aroused. 

As in the simple pericarditis, pain may be present, either sharp and 
stabbing or as a sense of distress and discomfort in the cardiac region. It 
is more frequent with effusion than in the plastic form. Pressure at the 
lower end of the sternum usually aggravates it. Dyspnoea is a common 
and important symptom, one which, perhaps, more than any other, excites 
suspicion of grave disorder and leads to careful examination of heart and 
lungs. The patient is restless, lies upon the left side or, as the effusion 
increases, sits up in bed. Associated with the dyspnoea is in many cases a 
peculiarly dusky, anxious countenance. The pulse is rapid, small, some- 
times irregular, and may present the characters known as pulsus paradoxus, 
in which during each inspiration the pulse-beat becomes very weak or is 
lost. These symptoms are due, in great part, to the direct mechanical 
effect of the fluid within the pericardium which embarrasses the heart's 
action. Other pressure effects are distention of the veins of the neck, 
dysphagia, which may be a marked symptom, and irritative cough from 
compression of the trachea. Aphonia is not uncommon, owing to compres- 
sion or irritation of the recurrent laryngeal as it winds round the aorta. 
Another important pressure effect is exercised upon the left lung. In 
massive effusion the pericardial sac occupies such a large portion of the 
antero-lateral region of the left side that the condition has frequently been 
mistaken for pleurisy. Even in moderate grades the left lung is somewhat 
compressed. This is an additional element in the production of the 
dyspnoea. 

Great restlessness, insomnia, and in the later stages low delirium and 
coma are symptoms in the more severe cases. Delirium and marked cere- 
bral symptoms are associated with the hyperpyrexia of rheumatic cases, 
but apart from the ordinary delirium there may be peculiar mental symp- 
toms. The patient may become melancholic and show suicidal tendencies. 



PERICARDITIS. 693 

In other cases the condition resembles closely delirium tremens. Sibson, 
who has specially described this condition, states that the majority of such 
cases recover. Chorea may also occur, as was pointed out by Bright. Epi- 
lepsy is a rare complication which has occurred during paracentesis. 

Physical Signs. — Inspection. — In children the prascordia bulges and 
with copious exudation the antero-lateral region of the left chest becomes 
enlarged. The intercostal spaces bulge somewhat and there may be marked 
cedema of the wall. The epigastrium may be more prominent. Perfora- 
tion externally through a space is very rare. Owing to the compression 
of the lung, the expansion of the left side is greatly diminished. The dia- 
phragm and left lobe *of the liver may be pushed down and may produce 
a distinct prominence in the epigastric region. 

Palpation. — A gradual diminution and final obliteration of the cardiac 
shock is a striking feature in progressive effusion. The position of the 
apex beat is not constant. In large effusions it is usually not felt. In chil- 
dren as the fluid collects the pulsation may be best seen in the fourth space, 
but this may not be the apex itself. Ewart maintains that the position of 
the apex beat is unaltered, or even depressed. The pericardial friction may 
lessen with the effusion, though it often persists at the base when no longer 
palpable over the right ventricle, or may be felt in the erect and not in the 
recumbent posture. Fluctuation can rarely, if ever, be detected. 

Percussion gives most important indications. The gradual distention 
of the pericardial sac pushes aside the margins of the lungs so that a large 
area comes in contact with the chest wall and gives a greatly increased 
percussion dulness. The form of this dulness is irregularly pear-shaped; 
the base or broad surface directed downward and the stem or apex directed 
upward toward the manubrium.. A valuable sign, to which Eotch called 
attention, is the absence of resonance in the right fifth intercostal space — 
the cardio-hepatic angle. In the left infrascapular area there may be a 
patch of diminished resonance or even flatness (Ewart). 

Auscultation. — The friction sound heard in the early stages may dis- 
appear when the effusion is copious, but often persists at the base or at 
the limited area of the apex. It may be audible in the erect and not in 
the recumbent posture. With the absorption of the fluid the friction re- 
turns. One of the most important signs is the gradual weakening of the 
heart-sounds, which with the increase in the effusion may become so muf- 
fled and indistinct as to be scarcely audible. The heart's action is usually 
increased and the rhythm disturbed. Occasionally a systolic endocardial 
murmur is heard. Early and persistent accentuation of the pulmonary 
second sound may be present (Warthin). 

Important accessory signs in large effusion are due to pressure on the 
left lung. The antero-lateral margin of the lower lobe is pushed aside and 
in some instances compressed, so that percussion in the axillary region, 
in and just below the transverse nipple line, gives a modified percussion 
note, usually a flat tympany. Variations in the position of the patient 
may change materially this modified percussion area, over which on auscul- 
tation there is either feeble or tubular breathing. 

Course. — Cases vary extremely in the rapidity with which the effusion 



694 



DISEASES OF THE CIRCULATORY SYSTEM. 



takes place. In every instance, when a pericardial friction murmur has 
been detected, the practitioner should first outline with care — using the 
aniline pencil or nitrate of silver — the upper and lateral limits of cardiac 
dulness, secondly mark the position of the apex beat, and thirdly note the 
intensity of the heart sounds. In many instances the exudation is slight 
in amount, reaches a maximum within forty-eight hours, and then grad- 
ually subsides. In other instances the accumulation is more gradual and 
progressive, increasing for several weeks. To such cases the term chronic 
has been applied. The rapidity with which a sero-fibrinous effusion may 
be absorbed is surprising. The possibility of the absorption of a purulent 
exudate is shown by the cases in which the pericardium contains semi-solid 
grayish masses in all stages of calcification. With sero-fibrinous effusion, 
if moderate in amount, recovery is the rule, with inevitable union, however, 
of the pericardial layers. In some of the septic cases there is a rapid for- 
mation of pus and a fatal result may follow in three or four days. More 
commonly, when death occurs with large effusion, it is not until the second 
or third week and takes place by gradual asthenia. 

Prognosis. — In the sero-fibrinous effusions the outlook is good, and 
a large majority of all the rheumatic cases recover. The purulent effusions 
are, of course, more dangerous; the septic cases are usually fatal, and re- 
covery is rare in the slow, insidious tuberculous forms. 

Diagnosis. — Probably no serious disease is so frequently overlooked 
by the practitioner. Post-mortem experience shows how often pericarditis 
is not recognized, or goes on to resolution and adhesion without attracting 
notice. In a case of rheumatism, watched from the outset, with the atten- 
tion directed daily to the heart, it is one of the simplest of diseases to diag- 
nose; but when one is called to a case for the first time and finds perhaps an 
increased area of precordial dulness, it is often very hard to determine with 
certainty whether or not effusion is present. 

The difficulty usually lies in distinguishing between dilatation of the 
heart and pericardial effusion. Although the differential signs are simple 
enough on paper, it is notoriously difficult in certain cases, particularly in 
stout persons, to say which of the conditions exists. The points which 
deserve attention are: 

(a) The character of the impulse, which in dilatation, particularly in 
thin-chested people, is commonly visible and wavy. 

(b) The shock of the cardiac sounds is more distinctly palpable in dila- 
tation. 

(c) The area of dulness in dilatation rarely has a triangular form; 
nor does it, except in cases of mitral stenosis, reach so high along the left 
sternal margin or so low in the fifth and sixth interspaces without visible 
or palpable impulse. An upper limit of dulness shifting with change of 
position speaks strongly for effusion. 

(d) In dilatation the heart-sounds are clearer, often sharp, valvular, 
or foetal in character; gallop rhythm is common, whereas in effusion the 
sounds are distant and muffled. 

(e) Rarely in dilatation is the distention sufficient to compress the lung 
and produce the tympanitic note in the axillary region. 



PERICARDITIS. 



695 



The number of excellent observers who have acknowledged that they 
have failed sometimes to discriminate between these two conditions, and 
who have indeed performed paracentesis cordis instead of paracentesis peri- 
cardii, is perhaps the best comment on the difficulties. 

Massive (1^ to 2 litre) exudations have been confounded with a pleural 
effusion. On more than one occasion the pericardium has been tapped 
under the impression that the exudate was pleuritic. The flat tympany 
in the infrascapular region, the absence of well-defined movable dulness, 
and the feeble, muffled sounds are indicative points. If the case has been 
followed from day to day there is rarely much difficulty; but it is different 
when a case presents a large area of dulness in the antero-lateral region 
of the left chest, and there is no to-and-fro pericardial friction murmur. 
Many of the cases have been regarded as encapsulated pleural effusions. 

The nature of the fluid cannot positively be . determined without aspira- 
tion; but a fairly accurate opinion can be formed from the nature of the 
primary disease and the general condition of the patient. In rheumatic 
cases the exudation is usually sero-fibrinous; in septic and tuberculous 
cases it is often purulent from the outset; in senile, nephritic, and tuber- 
culous cases the exudation is sometimes hemorrhagic. 

Treatment. — The patient should have absolute quiet, mentally and 
bodily, so as to reduce to a minimum the heart's action. Drugs given for 
this purpose, such as aconite or digitalis, are of doubtful utility. Local 
bloodletting by cupping or leeches is certainly advantageous in robust 
subjects, particularly in the cases of extension in pleuro-pneumonia. The 
ice-bag is of great value. It may be applied to the prsecordia at first for an 
hour or more at a time, and then continuously. It reduces the frequency 
of the heart's action and seems to retard the progress of an effusion. Blis- 
ters are not indicated in the early stage. 

When effusion is present, the following measures to promote absorption 
may be adopted: Blisters to the precordia, a practice not so much in vogue 
now as formerly. It is surprising, however, in some instances, how quickly 
an effusion will subside on their application. If the patient's strength is 
good, a purge every other morning may be given. The diet should be light, 
dry, and nutritious. In cases in which the pulse is strong and the consti- 
tutional disturbance not great, iodide of potassium may be of service, and 
the action of the kidneys may be promoted by the infusion of digitalis and 
acetate of potash. 

When the effusion is large, as soon as signs of serious impairment of 
the heart occur, as indicated by dyspnoea, small rapid pulse, dusky, anxious 
countenance, surgical measures should be resorted to, and paracentesis, or 
incision of the pericardium, at once be performed. With the sero-fibrinous 
exudate, such as commonly occurs after rheumatism, aspiration is suffi- 
cient; but when the exudate is purulent, the pericardium should be freely 
incised and freely drained. The puncture may be made in the fourth inter- 
space, either at the left sternal margin or 2.5 cm. (an inch) from it. If 
made in the fifth interspace it is well to puncture an inch and a half from 
the left sternal margin. In large effusions the pericardium can also be 
readily reached without danger by thrusting the needle upward and back- 



696 



DISEASES OF THE CIRCULATORY SYSTEM. 



ward close to the costal margin in the left costo-xiphoid angle. The re- 
sults of paracentesis of the pericardium have so far not been satisfactory. 
With an earlier operation in many instances and a more radical one in 
others — a free incision and not aspiration when the fluid is purulent — the 
percentage of recoveries will be greatly increased. Of 35 cases of suppura- 
tive pericarditis treated by incision 15 recovered and 20 died (Koberts, Am. 
Jr. Med. Sciences, Dec, 1897). 

Chronic Adhesive Pericarditis (Adherent Pericardium). — Two groups 
of cases may be recognized: 

(a) Simple adhesion of the peri- and epicardial layers. This is a com- 
mon sequence of pericarditis, and is frequently met with post mortem as 
an accidental lesion. It is not necessarily associated with disturbance in 
the function of the heart, and in a large proportion of the cases there is 
neither dilatation nor hypertrophy. 

(b) Adherent pericardium with chronic mediastinitis and union of the 
outer layer of the pericardium to the pleura and to the chest walls. This 
constitutes one of the most serious forms of cardiac disease, particularly in 
early life, and may lead to an extreme grade of hypertrophy and dilatation 
of the heart. Even with partial adhesion between the epicardium and 
pericardium there may be enormous hypertrophy under the conditions just 
mentioned. The symptoms of adherent pericardium are uncertain and in- 
definite. In the second group the features are those of hypertrophy and 
dilatation of the heart, later cardiac insufficiency, and in a few instances 
signs of extension of the mediastinitis to the peritonaeum, causing chronic 
proliferative peritonitis, with perihepatitis and perisplenitis.* Sudden 
death may occur after an unufeual exertion or during parturition (Eeynolds 
Wilson). 

The following are important points in the diagnosis: Inspection. — A 
majority of the signs of value come under this heading, (a) The prascordia 
is prominent and there may be marked asymmetry, owing to the enormous 
enlargement of the heart, (b) The extent of the cardiac impulse is greatly 
increased, and may sometimes be seen from the third to the sixth inter- 
spaces, and in extreme cases from the right parasternal line to outside the 
left nipple, (c) The character of the cardiac impulse. It is undulatory, 
wavy, and in the apex region there is marked systolic retraction, (d) Dia- 
phragm phenomena. J. W. Broadbent has called attention to a very valu- 
able sign in adherent pericardium. When the heart is adherent over a large 
area of the diaphragm there is with each pulsation a systolic tug, which 
may be communicated through the diaphragm to the points of its attach- 
ment on the wall, causing a visible systolic tugging. This has long been 
recognized in the region of the seventh or eighth ribs in the left parasternal 
line, but Dr. Broadbent called attention to the fact that it was frequently 
best seen on the left side behind, between the eleventh and twelfth ribs. 
With each systole there may be here a distinct, visible retraction of the chest 
wall. This is a very valuable and quite common sign. Sir William Broad- 
bent calls attention also to the fact that owing to the attachment of the 



* For illustrative cases see Arch, of Pediatrics, 1896. 



OTHER AFFECTIONS OF THE PERICARDIUM. 



697 



heart to the central tendon of the diaphragm this part does not descend 
with inspiration, during which act there is not the visible movement in the 
epigastrium, (e) Diastolic collapse of the cervical veins, the so-called Fried- 
reich's sign. This is not of much moment. 

Palpation. — The apex beat is fixed, and turning the patient on the left 
side does not alter its position. This I have found/ however, somewhat un- 
certain. On placing the hand over the heart there is felt a diastolic shock 
or rebound, which some have regarded as the most reliable of all signs of ad- 
herent pericardium. 

Percussion. — The area of cardiac dulness is usually much increased. In 
a majority of instances there are adhesions between the pleura and the peri- 
cardium, and the limit of cardiac dulness above and to the left may be 
fixed and is uninfluenced by deep inspiration. This, too, is an uncertain 
sign, inasmuch as there may be close adhesions between the pleura and the 
pericardium and between the pleura and the chest wall, which at the same 
time allow a very considerable degree of mobility to the edge of the lung. 

Auscultation. — The phenomena are variable and uncertain. In the 
cases in children with a history of rheumatism, endocarditis has usually 
been present. Even in the absence of chronic endocarditis, when the dila- 
tation reaches a certain grade there are murmurs of relative insufficiency, 
which, as in one case I have recorded, may be present not only at the mitral 
but also at the tricuspid and pulmonary orifices. Hale White has called 
attention to the fact that there may be a well-marked presystolic murmur 
in connection with adherent pericardium. This was present in one of my 
cases. 

The pulsus paradoxus, in which during inspiration the pulse-wave is 
small and feeble, is sometimes present, but it is not a diagnostic sign of 
either simple pericardial adhesion or of the cicatricial mediastino-peri- 
carditis. 

In children, chronic adhesive pericarditis and mediastinitis may be asso- 
ciated with proliferative peritonitis, perihepatitis, and perisplenitis, in 
which condition ascites may recur for months, or even for years. 



II. OTHER AFFECTIONS OF THE PERICARDIUM. 

(1) Hydropericardium. — Naturally there are in the pericardial sac a few 
cubic centimetres of clear, citron-colored fluid, which probably represents 
a post-mortem transudate. In certain conditions during life there may be 
a large secretion of serum forming what is known as dropsy of the peri- 
cardium. It occurs usually in connection with general dropsy, due to kid- 
ney or heart disease; more commonly the former. It rarely of itself proves 
fatal, though when the effusion is excessive it adds to the embarrassment of 
the heart and the lungs, particularly when the pleural cavities are the scat 
of similar exudation. There are rare instances in which effusion into the 
pericardium occurs after scarlet fever with few, if any, other dropsical 
symptoms. The physical signs are those already referred to in connection 
with pericarditis with effusion. It is frequently overlooked. 



608 



DISEASES OF THE CIRCULATORY SYSTEM. 



In rare cases the serum has a milky character — chylo-pericardiivm. 

(2) HaBmo-pericardium. — This condition, by no means uncommon, is met 
with in aneurism of the first part of the aorta, of the cardiac wall, or of the 
coronary arteries, and in rupture and wounds of the heart. Death usually 
follows before there is time for the production of symptoms other than 
those of rapid heart-failure due to compression. Particularly is this the 
case in aneurism. In rupture of the heart the patient may live for many 
hours or even days with symptoms of progressive heart-failure, dyspnoea, 
and the physical signs of effusion. 

As already mentioned, the inflammatory exudate of tubercle or cancer 
is often blood-stained. The same is true of the effusion in the pericarditis 
of Bright's disease and of old people. 

(3) Pneumopericardium. — Gas is rarely found in the pericardial sac, 
and is due, as a rule, to perforation from without, as in the case of stab 
wounds, or is the result of perforation from the lungs, oesophagus, or stom- 
ach. Perforation from a tuberculous cavity is a not uncommon cause. In 
those cases, formerly so puzzling, in which the gas is present shortly after 
death (a few hours), the gas bacillus (B. aerogenes capsulatus) will be found. 
In a case at the Royal Victoria Hospital, in which the gas bacillus was 
isolated, the diagnosis was made during life (Mcholls). As a result of per- 
foration, acute pericarditis is always excited, and the effusion rapidly be- 
comes purulent. The physical signs are remarkable. When the effusion 
is copious the fluid and gas together give a movable area of percussion dul- 
ness with marked tympany in the region of the gas. On auscultation, re- 
markable splashing, churning, metallic phenomena are heard with friction 
and possibly feeble, distant heart-sounds. Death follows rapidly, even in 
thirty-six hours, as in a case (the only one which I have seen) of perforation 
of the pericardium in cancer of the stomach. Except as a result of injury, 
the condition is not one for which treatment is available. In a case of 
perforation from without with signs of effusion, to enlarge the wound by 
free incision would be justifiable. 



II. DISEASES OF THE HEAET. 

I. ENDOCARDITIS. 

Inflammation of the lining membrane of the heart is usually confined to 
the valves, so that the term is practically synonymous with valvular endo- 
carditis. It occurs in two forms — acute, characterized by the presence of 
vegetations with loss of continuity or of substance in the valve tissues; 
chronic, a slow sclerotic change, resulting in thickening, puckering, and de- 
formity. 

Acute Endocakditis. 

This occurs in rare instances as a primary, independent affection; but 
in the great majority of cases it is an accident in various infective processes, 
so that in reality the disease does not constitute an etiological entity. 



ENDOCARDITIS. 



699 



For convenience of description we speak of a simple or benign, and a 
malignant or ulcerative endocarditis, between Avhich, however, there is no 
essential anatomical difference, as all gradations can be traced, and they 
represent but different degrees of intensity of the same process. 

Etiology. — Simple endocarditis does not constitute a disease of itself, 
but is invariably found with some other affection. The general experience 
of the profession has confirmed the original observation of Bouillaud as to 
the frequency of association of simple endocarditis with acute articular 
rheumatism. Possibly it is nothing in the disease itself, but simply an 
altered state of the fluid media — a reduction perhaps of the lethal influ- 
ences which they normally exert — permitting the invasion of the blood by 
certain micro-organisms. Tonsillitis, which in some forms is regarded as 
a rheumatic affection, may be complicated with endocarditis. Of the spe- 
cific diseases of childhood it is not uncommon in scarlet fever, while it is 
rare in measles and chicken-pox. In diphtheria simple endocarditis is rare. 
In small-pox it is not common. In typhoid fever I have met with it twice 
in 80 autopsies. 

In pneumonia both simple and malignant endocarditis are common. 
In 100 autopsies in this disease made at the Montreal General Hospital there 
were 5 instances of the former. Acute endocarditis is by no means rare in 
phthisis. I have met with it in 12 cases in 216 post mortems. 

In chorea simple warty vegetations are found on the valves in a large 
majority of all fatal cases, in 62 of 73 cases collected by me. There is no 
disease in which, post mortem, acute endocarditis has been so frequently 
found. And, lastly, simple endocarditis is met with in diseases associated 
with loss of flesh and progressive debility, as cancer, and such disorders as 
gout, diabetes, and Bright's disease. 

A very common form is that which occurs on the sclerotic valves in old 
heart-disease — the so-called recurring endocarditis. 

Malignant endocarditis is met with: (a) As a primary disease of the 
lining membrane of the heart or of its valves. 

(b) As a secondary affection in acute rheumatism, pneumonia, and in 
various specific fevers; or as an associated condition in septic processes. 

It is also known by the names of ulcerative, infectious, or diphtheritic 
endocarditis, but the term malignant seems most appropriate to charac- 
terize the essential clinical features of the disease. 

The existence of a primary endocarditis has been doubted; but there 
are instances in which persons previously in good health, without any his- 
tory of affections with which endocarditis is usually associated, have been 
attacked with symptoms resembling severe typhus or typhoid. In one case 
which I saw, death occurred on the sixth day and no lesions were found 
other than those of malignant endocarditis. 

The simple endocarditis of rheumatism rarely develops into the malig- 
nant form. In only 24 of 209 cases the symptoms of severe endocarditis 
arose in the progress of acute or subacute rheumatism. In only 3 of my 
Montreal cases was there a history of rheumatism either before or during 
the attacks. 

Malignant endocarditis is extremely rare in chorea. Of all acute dis- 



700 



DISEASES OF THE CIRCULATORY SYSTEM. 



eases complicated with severe endocarditis pneumonia probably heads the 
list. This fact, which had been referred to by several of the older writers, 
was brought out in a striking manner by the figures on which my Goul- 
stonian lectures were based. In 11 of the 23 Montreal cases the disease came 
on with lobar pneumonia, while it developed with this disease in 54 of the 
209 cases analyzed — indeed, the endocarditis which occurs in pneumonia 
seems to be of an unusually malignant type, as in 16 cases of my 100 autop- 
sies in this disease in which this lesion was present, 11 were of this form. 
This has been confirmed by Netter, Kanthack, and others. Meningitis was 
associated with endocarditis in 25 of the 209 cases, and in 15 there was also 
pneumonia. 

The affection may complicate erysipelas, septicaemia (from whatever 
cause) and puerperal fever and gonorrhoea. Malignant endocarditis is very 
rare in tuberculosis, typhoid fever, and diphtheria. 

It has been stated by many writers that endocarditis occurs in ague. 
With the unusual facilities for the study of this disease which I have had 
in the past twelve years I have not yet met with an instance. Unquestion- 
ably, in the majority of these cases, the intermittent pyrexia, which has 
been regarded as characteristic of the ague, has depended upon the endo- 
carditis. In dysentery cases have been described. In small-pox and scarlet 
fever, with which simple endocarditis is not infrequently complicated, the 
malignant form is extremely rare. 

Morbid Anatomy of Simple and Malignant Endocarditis. — Simple endo- 
carditis is characterized by the presence on the valves or on the lining mem- 
brane of the chambers of minute vegetations, ranging from 1 to 4 mm. 
in diameter, with an irregular and fissured surface, giving to them a warty 
or verrucose appearance. Often these little cauliflower-like excrescences are 
attached by very narrow pedicles. They are more common on the left side 
of the heart than the right, and occur on the mitral valves more often than 
on the aortic. The vegetations are usually above the line of closure of the 
valves. It is rare to see any swelling or macroscopic evidence of infiltration 
of the endocardium in the neighborhood of even the smallest of the granu- 
lations, and redness, indicative of distention of the vessels, is uncommon, 
even when they occur upon valves already the seat of sclerotic changes, in 
which capillary vessels extend to the edges. With time the vegetations may 
increase greatly in size, but in what may be called simple endocarditis the 
size rarely exceeds that mentioned above. 

The earliest vegetations consist of elements derived from the blood, and 
are composed of blood platelets, leucocytes, and fibrin in varying propor- 
tions. At a later stage they appear as small outgrowths of connective tissue. 
The transition of one form into the other can often be followed. The 
process consists of a proliferation of the endothelial cells and the cells of 
the subendothelial layer which gradually invade the fresh vegetation, and 
ultimately entirely replace it. The blood-cells and fibrin undergo disinte- 
gration and gradually they are removed. The whole process has received 
the name of " organization." Even when the vegetation has been entirely 
converted into granulations or connective tissue it is often found at autopsy 
to be capped with a thin layer of fibrin and leucocytes. 



ENDOCARDITIS. 



701 



Micro-organisms are generally, even if not invariably, found associated 
with the vegetations. They tend to be entangled in the granular and 
fibrillated fibrin or in the older ones to cap the apices. 

In both man and animals there is a form of chronic vegetative endo- 
carditis in which, without much or any loss of substance, the valves and 
chordae tendineae are covered with large, firm outgrowths. In several cases 
of this kind the clinical history has been characterized by a protracted fever 
of a marked remittent or even intermittent type. 

Subsequent Changes. — (1) The vegetations may become organized and 
the valve restored to a normal state (?). (2) The process may extend, and a 
simple may become an ulcerative endocarditis. (3) The vegetations may be 
broken off and carried in the circulation to distant parts. (4) The vegeta- 
tions become organized and disappear, but they initiate a nutritive change 
in the valve tissue which ultimately leads to sclerosis, thickening, and de- 
formity. The danger in any case of simple endocarditis is not immediate, 
but remote, and consists in this perversion of the normal processes of nutri- 
tion which results in sclerosis of the valves. 

A gradual transition from the simple to a more severe affection, to which 
the name malignant or ulcerative endocarditis has been given, may be traced. 
Practically every case of ulcerative endocarditis is attended by vegetations. 
In this form the loss of substance in the valve is more pronounced, the dep- 
osition — thrombus formation — from the blood is more extensive, and the 
micro-organisms are present in greater number and often show increased 
virulence. Ulcerative endocarditis is often found in connection with heart 
valves already the seat of chronic proliferative and sclerotic changes. 

In malignant endocarditis there is distinct loss of substance in the heart 
valve. This loss may be superficial and limited to the endocardium, or, 
what is more common, it involves deeper structures, and not very infre- 
quently leads to perforation of a valve, a septum, or even of the heart itself. 

Upon microscopical examination the affected valve shows necrosis, with 
more or less loss of substance; the necrotic tissue is devoid of preserved 
nuclei and presents a coagulated appearance. Upon it a mixture of blood 
platelets, fibrin — granular or fibrillated — and leucocytes enclosing masses 
of micro-organisms are met with. The subjacent tissue often shows scle- 
rotic thickening and always infiltration with exuded granulation tissue-cells. 

Parts affected. — The following figures, taken from my Goulstonian lec- 
tures at the Royal College of Physicians, give an approximate estimate of 
the frequency with which in 209 cases different parts of the heart were 
affected in malignant endocarditis: Aortic and mitral valves together, in 
41; aortic valves alone, in 53; mitral valves alone, in 77; tricuspid in 19; 
the pulmonary valves in 15; and the heart walls in 33. In 9 instances the 
right heart alone was involved, in most cases the auriculo-ventricular valves. 

Mural endocarditis is seen most often at the upper part of the septum 
of the left ventricle. Next in order is the endocarditis of the left auricle 
on the postero-external wall. The vegetations may extend, as in a recent 
case in my wards, along the intima of the pulmonary artery into the hilum 
of the lung. The ulcerative changes may lead to perforation of a valve seg- 
ment, erosion of the chorda? tendineae, perforation of the septum, or even 



702 



DISEASES OF THE CIRCULATORY SYSTEM. 



of the heart itself. A common result of the ulceration is the production of 
valvular aneurism. In three fourths of the cases the affected valves present 
old sclerotic changes. The process may extend to the aorta, producing, as 
in one of my cases, extensive endarteritis with multiple acute aneurisms. 

Associated Lesions. — The associated pathological changes are partly 
those of the primary disease to which the endocarditis is secondary and 
partly those due to embolism. In the endocarditis of septic processes there 
is the local lesion — an acute necrosis, a suppurative wound, or puerperal dis- 
ease. In many cases the lesions are those of pneumonia, rheumatism, or 
other febrile processes. The changes due to embolism constitute the most 
striking features, but it is remarkable that in some instances, even with 
endocarditis of a markedly ulcerative character, there may be no trace of 
embolic processes. 

The infarcts may be few in number — only one or two, perhaps, in the 
spleen or kidney — or they may exist in hundreds throughout the various 
parts of the body. They may present the ordinary appearance of red or 
white infarcts of a suppurative character. They are most common in the 
spleen and kidneys, though they may be numerous in the brain, and in 
many cases are very abundant in the intestines. In right-sided endocar- 
ditis there may be infarcts in the lungs. In many of the cases there are 
innumerable miliary abscesses. Acute suppurative meningitis was met 
with in 5 of 23 of the Montreal cases, and in over 10 per cent of the 209 
cases analyzed in the literature. Acute suppurative parotitis also may 
occur. 

Bacteriology. — No distinction in the micro-organisms found in the two 
forms of endocarditis can be made. In both the pyogenic cocci — strepto- 
cocci, staphylococci, pneumococci, and gonococci — are the most frequent 
bacteria met with. More rarely, especially in the simple vegetative endo- 
carditis, the bacilli of tuberculosis, typhoid fever, and anthrax have been 
encountered. The bacillus coli communis has also been found, and Howard 
has described a case of malignant endocarditis due to an attenuated form 
of the diphtheria bacillus. Flexner * has analyzed 34 cases of acute endo- 
carditis associated with chronic renal and cardiac disease, and found the 
micrococcus lanceolatus and the streptococcus pyogenes present each twelve 
times, the staphylococcus three times. Other bacteria encountered were 
bacillus pyocyaneus, coli, and influenzae, and the gonococcus. 

Symptoms. — Neither the clinical course nor the physical signs of 
simple endocarditis are in any respect characteristic. The great majority 
of the cases are latent and there is no indication whatever of cardiac mis- 
chief. Experience has taught us that endocarditis is frequently found post 
mortem in persons in whom it was not suspected during life. There are 
certain features, however, by which its presence is indicated with a degree 
of probability. The patient, as a rule, does not complain of any pain or 
cardiac distress. In a case of acute rheumatism, for example, the symptoms 
to excite suspicion would be increased rapidity of the heart's action, per- 
haps slight irregularity, and an increase in the fever without aggravation 



* Journal of Experimental Medicine, 1896, i, p. 559. 



ENDOCARDITIS. 



703 



of the joint trouble. Rows of tiny vegetations on the mitral or on the aortic 
segments seem a trifling matter to excite fever, and it is difficult in the 
endocarditis of febrile processes to say definitely in every instance that an 
increase in the fever depends upon the endocardial complication. But a 
study of the recurring endocarditis — which is of the warty variety, con- 
sisting of minute beads on old sclerotic valves — shows that this process may 
be associated, for days or weeks at a time, with slight fever ranging from 
100° to 102 Palpitation may be a marked feature and is a symptom upon 
which certain authors lay great stress. 

The diagnosis of the condition rests upon physical signs which are 
notoriously uncertain. The presence of a murmur at one or other of the 
cardiac areas in a case of fever is often regarded as indicative of the exist- 
ence of endocarditis. This extremely common mistake has arisen from the 
fact that the bruit de souffle or bellows murmur is common to endocarditis 
and a number of other conditions which have nothing to do with it. At 
first there may be only a slight roughening of the first sound, which may 
gradually develop into a distinct murmur. Reduplication and accentua- 
tion of the pulmonic second sound are frequently present. 

It is difficult to give a satisfactory clinical picture of malignant endo- 
carditis because the modes of onset are so varied and the symptoms so 
diverse. Arising in the course of some other disease, there may be simply 
an intensification of the fever or a change in its character. In a majority 
of the cases there are present certain general features, such as irregular 
pyrexia, sweating, delirium, and gradual failure of strength. 

Embolic processes may give special characters, such as delirium, coma 
or paralysis from involvement of the brain or its membranes, pain in the' 
side and local peritonitis from infarction of the spleen, bloody urine from 
implication of the kidneys, impaired vision from retinal haemorrhage, and 
suppuration, and even gangrene, in various parts from the distribution of 
the emboli. 

Two special types of the disease have been recognized — the septic or 
pysemic and the typhoid. Other cases closely resemble true intermittent 
fever. In some the cardiac symptoms are most prominent, while in others 
again the main symptoms may be those of an acute affection of the cerebro- 
spinal system. 

The septic type is met with usually in connection with an external 
wound, the puerperal process, or an acute necrosis. There are rigors, sweats, 
irregular fevers, and all of the signs of septic infection. The heart symp- 
toms may be completely masked by the general condition, and attention 
called to them only on the occurrence of embolism. In a most remarkable 
sub-group of this type the disease may simulate a quotidian or a tertian 
ague. The symptoms may develop in persons with chronic heart-disease 
without any external lesions. These cases may be much prolonged — for 
three or four months, or even longer, as in one of Bristowe's. The ex- 
istence in some of these instances of a previous genuine malaria has been 
a very puzzling circumstance. 

The typhoid type is by far the most common and is characterized by a 
less irregular temperature, early prostration, delirium, somnolence, and coma, 
44 



704 



DISEASES OF THE CIRCULATORY SYSTEM. 



relaxed bowels, sweating, which may be of a most drenching character, 
petechial and other rashes, and occasionally parotitis. The heart symptoms 
may be completely overlooked, and in some instances the most careful 
examination has failed to discover a murmur. 

Under the cardiac group, as suggested by Bramwell, may be consid- 
ered those cases in which patients with chronic valve disease are attacked 
with marked fever and evidence of recent endocarditis. Many such cases 
present symptoms of the pyaemic and typhoid character and may run a 
most acute course. In others the course is chronic, lasting for weeks or 
months. I have reported two cases of this chronic vegetative endocarditis, 
with intermittent fever, one of more than a year's duration. The autopsies 
showed extensive vegetative and ulcerative disease of the mitral valves. 

There are cases in which it is often difficult to decide whether malig- 
nant endocarditis is present or not. Thus, a patient with aortic valve dis- 
ease is under treatment for failing compensation and begins to have irregu- 
lar fever with restlessness and cardiac distress; embolic phenomena may 
develop — sudden hemiplegia, pain in the region of the spleen, or bloody 
urine, or perhaps peripheral embolism. There may be a low delirium and 
the case may run a tolerably acute course; but in other instances the fever 
subsides and recovery occurs. 

In what may be termed the cerebral group of cases the clinical picture 
may simulate a meningitis, either basilar or cerebro-spinal. There may 
be acute delirium or, as in three of the Montreal cases, the patient may be 
brought into the hospital unconscious. Heineman reports an instance, with 
autopsy, in which the clinical picture was that of an acute cerebro-spinal 
meningitis. 

Certain special symptoms may be mentioned. The fever is not always 
of a remittent type, but may be high and continuous. Petechial rashes 
are very common and render the similarity very strong to certain cases of 
typhoid and cerebro-spinal fever. In one case the disease was thought 
to be hemorrhagic small-pox. Erythematous rashes are not uncommon. 
The sweating may be most profuse, even exceeding that which occurs in 
phthisis and ague. Diarrhoea is not necessarily associated with embolic 
lesions in the intestines. Jaundice has been observed and cases are on 
record which were mistaken for acute yellow atrophy. 

The heart symptoms may be entirely latent and are not found unless a 
careful search be made. Even on examination there may be no murmur 
present. Instances are recorded by careful observers, in which the examina- 
tion of the heart has been negative. Cases with chronic valve disease usu- 
ally present no difficulty in diagnosis. 

The course of the disease is varied, depending largely upon the nature 
of the primary trouble. Except in the disease grafted upon chronic valvu- 
litis the course is rarely extended beyond five or six weeks. As already 
mentioned, there are instances in which the disease is prolonged for months. 
The most rapidly fatal case on record is described by Eberth, the duration 
of which was scarcely two days. 

Diagnosis. — In many cases the detection of the disease is very diffi- 
cult; in others, with marked embolic symptoms, it is easy. From simple 



ENDOCARDITIS. 



705 



endocarditis it is readily distinguished, though confusion occasionally 
occurs in the transitional stage, when a simple is developing into a malig- 
nant form. The constitutional symptoms are of a graver type, the fever 
is higher, rigors are common, and septic and typhoid symptoms develop. 
Perhaps a majority of the cases not associated with puerperal processes or 
bone-disease are confounded with typhoid fever. A differential diagnosis 
may even be impossible, particularly when we consider that in typhoid 
fever infarctions and parotitis may occur. The diarrhoea and abdominal 
tenderness may also be present, which with the stupor and progressive 
asthenia make a picture not to be distinguished from this disease. Points 
which may guide us are: The more abrupt onset in endocarditis, the ab- 
sence of any regularity of the pyrexia in the early stage of the disease, and 
the cardiac pain. Oppression and shortness of breath may be early symp- 
toms in malignant endocarditis. Eigors, too, are not uncommon. There 
is a marked leucocytosis in infective endocarditis. Between pyaemia and 
malignant endocarditis there are practically no differential features, for 
the disease really constitutes an arterial pywmia (Wilks). In the acute cases 
resembling malignant fevers, the diagnosis is usually made of typhus, 
typhoid, cerebro-spinal fever, or even of haemorrhagic small-pox. The in- 
termittent pyrexia, occurring for weeks or months, has led in some cases 
to the diagnosis of malaria, but this disease could now be positively excluded 
by the blood examination. Blood cultures may aid greatly in the diagnosis. 

The cases usually terminate fatally. The instances of recovery are those 
more subacute forms, the so-called recurring endocarditis developing on 
old sclerotic valves in cases of chronic heart-disease. 

Treatment. — We know no measures by which in rheumatism, chorea, 
or the eruptive fevers the onset of endocarditis can be prevented. As it is 
probable that many cases develop, particularly in children, in mild forms 
of these diseases, it is well to guard the patients against taking cold and 
insist upon rest and quiet, and to bear in mind that of all complications 
an acute endocarditis, though in its immediate effects harmless, is per- 
haps the most serious. This statement is enforced by the observations of 
Sibson that on a system of absolute rest the proportion of cases of rheu- 
matism attacked by endocarditis was less than of those who were not so 
treated. 

It is doubtful whether the salicylates in rheumatism have an influence 
in reducing the liability to endocarditis. When the endocarditis is present 
we know no remedies which will definitely influence the valvular lesions. 
If there is much vascular excitement aconite may be given and an ice-bag 
placed over the heart. 

The salicylates are strongly advised by some writers and the sulpho- 
carbolatcs have been recommended by Sansom. In the severer cases of 
malignant endocarditis the treatment is practically that of septicemia. 

Chronic Endocarditis. 

Tli is condition, which is a sclerosis of the valve, may be primary, but is 
oftcner secondary to acute endocarditis, particularly the rheumatic form. 



706 



DISEASES OF THE CIRCULATORY SYSTEM. 



It is essentially a slow, insidious process which leads to deformity of the 
valve segment and is the foundation of chronic valvular disease. 

Certain poisons appear capable of initiating the change, such as alco- 
hol, syphilis, and gout, though we are at present ignorant of the way in 
which they act. A very important factor, particularly in the case of the 
aortic valves, is the strain of prolonged and heavy muscular exertion. In 
no other way can be explained the occurrence of so many cases of sclerosis 
of the aortic valves in young and middle-aged men whose occupations neces- 
sitate the overuse of the muscles. 

Morbid Anatomy. — Vegetations in the form in which they occur 
fn. acute endocarditis are not present. In the early stage, which we have 
frequent opportunities of seeing, the edge of the valve is a little thickened 
and perhaps presents a few small nodular prominences, which in some 
cases may represent the healed vegetations of the acute process. In the 
aortic valves the tissue ahout the corpora Arantii is first affected, producing 
a slight thickening with an increase in the size of the nodules. The sub- 
stance of the valve may lose its translucency, and the only change noticeable 
be a grayish opacity and a slight loss of its delicate tenuity. In the auriculo- 
ventricular valves these early changes are seen just within the margin 
and here it is not uncommon to find swellings of a grayish-red, somewhat 
infiltrated appearance, almost identical with the similar structures on the 
intima of the aorta in arterio-sclerosis. Even early there may be seen yel- 
low or oj)aque-white subintimal fatty degenerated areas. As the sclerotic 
changes increase, the fibrous tissue contracts and produces thickening and 
deformity of the segment, the edges of which become round, curled, and 
incapable of that delicate apposition necessary for perfect closure. A sig- 
moid valve, for instance, may be narrowed one fourth or even one third 
across its face, the most extreme grade of insufficiency being induced with- 
out any special deformity and without any definite narrowing of the arterial 
orifice. In the auriculo-ventricular segments a simple process of thicken- 
ing and curling of the edges of the valves, inducing a failure to close with- 
out forming any obstruction to the normal course of the blood-flow, is less 
common. Still, we meet with instances at the mitral orifice, particularly 
in children, in which the edges of the valves are curled and thickened, 
so that there is extreme insufficiency without any material narrowing of the 
orifice. More frequently, as the disease advances, the chorda? tendineas 
become thickened, first at the valvular ends and then along their course. 
The edges of the valves at their angles are gradually drawn together and 
there is a definite narrowing of the orifice, leading in the aorta to more 
or less stenosis and in the left auriculo-ventricular orifice — the two sites 
most frequently involved — to constriction. Finally, in the sclerotic and 
necrotic tissues lime salts are deposited and may even reach the deeper 
structures of the fibrous rings, so that the entire valve becomes a dense cal- 
careous mass with scarcely a remnant of normal tissue. The chordae ten- 
dineee may gradually become shortened, greatly thickened, and in extreme 
cases the papillary muscles are implanted directly upon the sclerotic and 
deformed valve. The apices of the papillary muscles usually show marked 
fibroid change. 



CHRONIC VALVULAR DISEASE. 



707 



In all stages of the process the vegetations of simple endocarditis may 
be present, and upon sclerotic valves we find the severer, ulcerative form of 
the disease. 

Chronic mural endocarditis produces cicatricial-like patches of a gray- 
ish-white appearance which are sometimes seen on the muscular trabecular 
of the ventricle or in the auricles. It often occurs in association with myo- 
carditis. 

The frequency with which chronic endocarditis is met with may be 
gathered from the following figures: In the statistics, amounting to from 
12,000 to 14,000 autopsies, reported from Dresden, Wurzburg, and Prague 
the percentage ranged from four to nine. The relative frequency of involve- 
ment of the various valves is thus given in the collected statistics of Parrot: 
The mitral orifice was involved in 621, the aortic in 380, the tricuspid in 
46, and the pulmonary in 11. This gives 57 instances in the right to 1,001 
in the left heart. 

The endocarditis of the foetus is usually of the sclerotic form and in- 
volves the valves of the right more frequently than those of the left side. 



II. CHRONIC VALVULAR DISEASE. 

1. Geneeal Introduction. 

The incidence of valvular lesions may be gathered from the following 
figures compiled by Gillespie from the records of the Royal Infirmary, Edin- 
burgh: Of 2,368 cases with cardiac lesions, valvular disease occurred in 80.8 
per cent; endocarditis and pericarditis in 5.3; myocardial lesions in 11.9 
per cent; 66.2 per cent of the cases were in males. 

Effects of Valve Lesions. — The general influence on the work of the 
heart may be briefly stated as follows: The sclerosis induces insufficiency 
or stenosis, which may exist separately or in combination. The narrowing 
retards in a measure the normal outflow and the insufficiency perm-its the 
blood current to take an abnormal course. In both instances the effect is 
dilatation of a chamber. The result in the former case is an increase in 
the difficulty which the chamber has in expelling its contents through the 
narrow orifice; in the other, the overfilling of a chamber by blood flowing 
into it from an improper source, as, for instance, in mitral insufficiency, 
when the left auricle receives blood both from the pulmonary veins and 
from the left ventricle. 

The cardiac mechanism is fully prepared to meet ordinary grades of 
dilatation which constantly occur during sudden exertion. A man, for in- 
stance, at the end of a hundred-yard race has his right chambers greatly 
dilated and his reserve cardiac power worked to its full capacity. The slow 
progress of the sclerotic changes brings about a gradual, not an abrupt, in- 
sufficiency, and the moderate dilatation which follows is ai first overcome 
by the exercise of the ordinary reserve strength of the heart muscle. Grad- 
ually a new factor is introduced. The reserve power which is capable of 
meeting sudden emergencies in such a remarkable manner is unable to cope 



708 



DISEASES OF THE CIRCULATORY SYSTEM. 



long with a permanent and perhaps increasing dilatation. More work has 
to be done and, in accordance with definite physiological laws, more power 
is given by increase of the muscles. The heart hypertrophies and the effect 
of the valve lesion becomes, as we say, compensated. The equilibrium of 
the circulation is in this way maintained. 

The nature of the process with which we have to deal is graphically 
illustrated in the accompanying diagrams, which we owe to Martius, of 
Eostock. The perpendicular lines in the figures represent the power of 
work of the heart. While the muscle in the healthy heart (Diagram I) has 
at its disposal the maximal force, a c, it carries on its work under ordinary 
circumstances (when the body is at rest) with the force a b. The force b c 
is reserve force, by means of which the heart accommodates itself to greater 
exertion. 

If now there be a gross valvular lesion, the force required to do the ordi- 
nary work of the heart (at rest) becomes very much increased (Diagram II). 
But in spite of this enormous call for force, insufficiency of the heart muscle 
does not necessarily result, for the working force required is still within the 



Reserve-force = i 
Accommodation- \ 
capacity 



Reserve-force = 
Accommodation- * 
capacity 



Power of work 
(body at rest) 



I. Normal heart 



V Power of work 
' (body at rest) 



a! 



Total power of heart 
less than amount needed 
w-hen the body is at est. 
Insufficiency of trie heart 



II. Heart in valvular disease in 
stage of compensation 

Chart XVI. 



III. Heart in uncompensated 
valvular disease 



limits of the maximal power of the heart, a x b ± , being less than a t c t . The 
muscle accommodates itself to the new conditions by making its reserve 
force mobile (experiment of Eosenbach). If nothing further occurred, 
however, this condition could not be permanently maintained, for there 
would be left over for emergencies only the small reserve force, b 1 y. Even 
when at rest the heart would be using continuously almost i£s entire maxi- 
mal force. Any slight exertion requiring more extra force than that repre- 
sented by the small value b 1 y (say the effort required on walking or on 



CHRONIC VALVULAR DISEASE. 



709 



going upstairs) would bring the heart to the limit of its working power, 
and palpitation and dyspnoea would appear. Such a condition does not 
last long. The working power of the heart graduall) T increases. More and 
more exertion can be borne without causing dyspnoea, for the heart hyper- 
trophies. Finally, a new, more or less permanent condition is attained, in 
that the hypertrophied heart possesses the maximal force, a x , c x . Owing to 
the increase in volume of the heart muscle, the total force of the heart is 
greater absolutely than that of the normal heart by the amount y, c x . It is, 
however, relatively less efficient, for its reserve force is much less than that 
of the healthy heart. Its capacity for accommodating itself to unusual calls 
upon it is accordingly permanently diminished. 

Turning now to the disturbances of compensation, it is to be distinctly 
borne in mind that any heart, normal or diseased, can become insufficient 
whenever a call upon it exceeds its maximal working capacity. The liability 
to such disturbance will depend, above all, upon the accommodation limits 
of the heart — the less the width of the latter, the easier will it be to go 
beyond the heart's efficiency. A comparison of Diagrams I and II will im- 
mediately make it clear that the heart in valvular disease will much earlier 
become insufficient than the heart of a healthy individual. If the heart 
muscle is compelled to do maximal or nearly maximal work for a long time, 
it becomes exhausted. It is obvious that the heart in valvular disease has 
on account of its small amount of reserve force to do maximal or nearly 
maximal work far more frequently than does the normal heart. The power 
of the heart may become decreased to the amount necessary simply to carry 
on the work of the heart when the body is at rest, or it may cease to be 
sufficient even for this. The reserve force gained through the compensa- 
tory process may be entirely lost (Diagram III). If the loss be only tem- 
porary, the exhausted heart muscle quickly recovering, the condition is 
spoken of as a " disturbance of compensation/' The term " loss of com- 
pensation " is reserved for the condition in which the disturbance is con- 
tinuous. 

2. Aortic Incompetency. 

Incompetency of the aortic valves arises either from inability of the 
valve segments to close an abnormally large orifice or more commonly from 
disease of the segments themselves. This best-defined and most easily 
recognized of valvular lesions was first carefully studied by Corrigan, whose 
name it sometimes bears. 

Etiology and Morbid Anatomy. — It is more frequent in males 
than in females, affecting chiefly able-bodied, vigorous men at the middle 
period of life. The ratio which it bears to other valve diseases has been 
variously given as from 30 to 50 per cent. 

There are four groups of cases: I. Those due to congenital malformation, 
particularly fusion of two of the cusps — most commonly those behind which 
the coronary arteries are given off. It is probable that an aortic orifice 
may be competent with this bicuspid state of the valves, but a great dan- 
ger is the liability of these malformed segments to sclerotic endocarditis. 
Of 17 cases which 1 have reported all presented sclerotic changes, and the 



no 



DISEASES OF THE CIRCULATORY SYSTEM. 



majority of them had; during life, the clinical features of chronic heart- 
disease. 

II. The endocarditic group. Endocarditis may produce an acute insuffi- 
ciency by ulceration and destruction of the valves; such cases are usually 
rapidly fatal. The valvulitis of rheumatism and of the fevers, while less 
rarely aortic, is common enough in children, and the insufficiency is caused 
by nodular excrescences at the margins or in the valves, which may ulti- 
mately become calcified; more often it induces a slow sclerosis of the valves 
with adhesions, causing also some degree of narrowing. 

III. The arteriosclerotic group. By far the most frequent cause of in- 
sufficiency is a slow, progressive sclerosis of the segments, resulting in a 
curling of the edges, which lessens the working surface of the valve. This 
form is most often met with in strong, able-bodied men among the work- 
ing classes. There are three main factors in its production: First, strain — 
not a sudden, forcible strain, but a persistent increase of the normal tension 
to which the segments are subject during the diastole of the ventricle. Of 
circumstances increasing this tension, repeated and excessive use of the 
muscles is perhaps the most important. So often is this form of heart- 
disease found in persons devoted to athletics that it is sometimes called 
the " athlete's heart." Secondly, alcohol, which not only raises the tension 
in the arterial system, but directly promotes arterio-sclerosis. A com- 
bination of these two causes is extremely common. Thirdly, syphilis, 
which may be only one of several elements in inducing early arterial change, 
an added factor to the wear and tear of the tubing. There is a small group, 
usually in young men, in which syphilis causes a localized arterio-sclerosis 
at the root of the aorta, either involving the valves themselves or more 
frequently causing dilatation of the aortic ring with relative insufficiency. 
The endarteritis may be singularly localized, even annular, sometimes 
patchy. It may be difficult or impossible from the lesion itself to determine 
the syphilitic nature; the youth of the patient, the peculiar localization, the 
history of syphilis, and the existence of syphilitic lesions elsewhere, may 
render the diagnosis tolerably certain. I am in the habit of enforcing 
upon my students the etiological lesson of this type of aortic insufficiency 
by a reference to Bacchus and Vulcan, at whose shrines a majority of 
patients with aortic insufficiency have worshipped, and not a few at those 
of Mars and Venus. 

The condition of the valves is such as has already been described in 
chronic endocarditis. It may be noted, however, how slight a grade of 
curling may produce serious incompetency. Associated with the valve dis- 
ease is, in a majority of cases, a more or less advanced arterio-sclerosis 
of the arch of the aorta, one serious defect of which may be a narrowing 
of the orifices of the coronary arteries. The sclerotic changes are often 
combined with atheroma, either in the fatty or calcareous stage. This may 
exist at the attached margin of the valves without inducing insufficiency. 
In other instances insufficiency may result from a calcified spike projecting 
from the aortic attachment into the body of the valve, and so preventing 
its proper closure. Some writers (Peter) have laid great stress upon the 
extension of the endarteritis to the valve, and would separate the instances 



CHRONIC VALVULAR DISEASE. 



Til 



of this kind from those of simple valvular endocarditis. Anatomically one 
can usually recognize the arterio-sclerotic variety by the smooth surface, 
the rounded edges, and the absence of excrescences. 

IV. Insufficiency may be induced by rupture of a segment — a very rare 
event in healthy valves, but not uncommon in disease, either from excessive 
effort during heavy lifting or from the ordinary endarterial strain on a 
valve eroded and weakened by ulcerative endocarditis. 

Relative insufficiency of the sigmoid valves, due to dilatation of the 
aortic ring, is not very infrequent. It occurs in extensive arterial sclerosis 
of the ascending portion of the arch with great dilatation just above the 
valves. The valve segments are usually involved with the arterial coats, 
but the changes in them may be very slight. In aneurism just above the 
aortic ring, relative insufficiency of the valve may be present. 

It would appear from the careful measurements of Beneke that the 
aortic orifice, which at birth is 20 mm., increases gradually with the growth 
of the heart until at one-and-twenty it is about 60 mm. At this it remains 
until the age of forty, beyond which date there is a gradual increase in the 
size up to the age of eighty, when it may reach from 68 to 70 mm. There 
is thus at the very period of life in which sclerosis of the valve is most 
common a physiological tendency toward the production of a state of rela- 
tive insufficiency. 

The insufficiency may be combined with various grades of narrowing, 
particularly in the endocarditic group. In a majority of the cases of the 
arterio-sclerotic form there are no signs of stenosis. On the other hand, 
aortic stenosis almost without exception is associated with some grade, how- 
ever slight, of regurgitation. 

Effects. — The direct effect of aortic insufficiency is the regurgitation 
of blood from the artery into the ventricle, causing an overdistention of 
the cavity and a reduction of the blood column; that is, a relative anaemia 
in the arterial tree. As an immediate effect of the double blood-flow into 
the left ventricle dilatation of the chamber occurs, and finally hypertrophy. 
In this way the valve defect is compensated, and as with each ventricular 
systole a larger amount of blood is propelled into the arterial system, the 
regurgitation of a certain amount during diastole does not, for a time at 
least, seriously impair the nutrition of the peripheral parts. In this valve 
lesion dilatation and hypertrophy reach their most extreme limit. The 
heaviest hearts on record are described in connection with this affection. 
The so-called bovine heart, cor bovinum, may weigh 35 or 40 ounces, or 
even, as in a case of Dulles's, 48 ounces. The dilatation is usually extreme, 
and is in marked contrast to the condition of the chamber in cases of pure 
aortic stenosis. The papillary muscles may be greatly flattened. The 
mitral valves arc usually not seriously affected, though the edges may pre- 
sent slight sclerosis, and there is often relative incompetency, owing to 
distention of the mitral ring. Dilatation and hypertrophy of the Left 
auricle arc common, and secondary enlargement of the right heart occurs 
in all cases of long standing. In the arterio-sclerotic group there is an 
ever present possibility of narrowing of the orifices of the coronary arteries 
or an extension of the sclerosis to their branches, leading to fibroid myo- 



712 



DISEASES OF THE CIRCULATORY SYSTEM. 



carditis. In the endocarditic cases, particularly those following rheuma- 
tism, the intima is perfectly smooth, and the arch with its main branches 
not dilated. A normal aorta may be found post mortem even when during 
life there have been the most characteristic signs of enlargement of the 
arch and of dilatation of the innominate and right carotid. I have even 
known the condition of aneurism to be diagnosed when post mortem no 
trace of dilatation or sclerosis was found, only an extreme grade of insuffi- 
ciency with enormous cardiac dilatation and hypertrophy. The so-called 
dynamic dilatation of the arch is best seen in certain of these cases. Al- 
though the coronary arteries, as shown by Martin and Sedgwick, are filled 
during the ventricular systole, the circulation in them must be embarrassed 
in aortic incompetency. They must miss the effect of the blood-pressure 
in the sinuses of Valsalva during the elastic recoil of the arteries, which 
surely aids in keeping the coronary vessels full. The arteries of the body 
usually present more or less sclerosis consequent upon the strain which 
they undergo during the forcible ventricular systole. 

Symptoms. — The condition is often discovered accidentally in per- 
sons who have not presented any features of cardiac disease. 

Headache, dizziness, flashes of light, and a feeling of faintness on ris- 
ing quickly are among the earliest symptoms. Palpitation and cardiac 
distress on slight exertion are common. Long before any signs of failing 
compensation pain may become a marked and troublesome feature. It is 
extremely variable in its manifestations. It may be of a dull, aching char- 
acter confined to the praecordia. More frequently, however, it is sharp 
and radiating, and is transmitted up the neck and down the arms, particu- 
larly the left. Attacks of true angina pectoris are more frequent in this 
than in any other valvular disease. Anaemia is also common, much more 
so than in aortic stenosis or in mitral affections. 

More serious symptoms, as compensation fails, are shortness of breath 
and oedema of the feet. The attacks of dyspnoea are liable to come on at 
night, and the patient has to sleep with the head high or even in a chair. 
Cyanosis is rare. It is most commonly due to complicating valve disease, 
or it is stated that it may result from bulging of the septum ventriculorum 
and encroachment upon the right ventricle. Of respiratory symptoms cough 
is common, due to the congestion of the lungs or oedema. ' Haemoptysis is 
less frequent than in mitral disease. I have reported a case in which it 
was profuse and believed to be due to tuberculosis of the lungs, inasmuch 
as the patient was admitted in a state of emaciation and profound ex- 
haustion. General dropsy is not common, but oedema of the feet may occur 
early and is sometimes due to the anaemia, at others to the venous stasis, 
at times to both. LTnless there is coexisting disease of the mitral valve, 
it is rare in aortic incompetency for the patient to die with general ana- 
sarca. Sudden death is frequent; more so in this than in other valvular 
diseases. As compensation fails the patient takes to bed and slight irregu- 
lar fever, associated usually with a recurring endocarditis, is not uncom- 
mon toward the close. Embolic symptoms are not infrequent — pain in the 
splenic region with enlargement of the organ, haematuria, and in some 
cases paralysis. Distressing dreams and disturbed sleep are more common 
in this than in other forms of valvular disease. 



CHRONIC VALVULAR DISEASE. 



713 



Here may appropriately be mentioned the connection between mental 
symptoms and cardiac disease, as they are oftenest seen with this lesion. 
An admirable account of the relations between insanity and disease of the 
heart is to be found in Mickle's Goulstonian lectures for 1888. In general 
medical practice we seldom find marked mental symptoms, except toward 
the close of the disease, when there may be delirium, hallucinations, and 
morbid impulses. It is to be remembered that in many heart cases this 
terminal delirium is ursemic. The irritability and peevishness sometimes 
found in persons the subject of organic heart-disease can not, I think, be 
associated with it in any special manner. We do meet insanity, breaking- 
out in patients with aortic and mitral disease, in the stage of compensation, 
which appears to be related definitely to the cardiac lesion. It is important 
to bear this in mind, for patients occasionally display suicidal tendencies. 
I have twice had patients throw themselves from a window of the ward. 

Physical Signs. — Inspection shows a wide and forcible area of cardiac 
impulse with the apex beat in the sixth or seventh interspace, and perhaps 
as far out as the anterior axillary line. In young subjects the prsecordia 
may bulge. On palpation a thrill, diastolic in time, is occasionally felt, 
but is not common. The impulse is usually strong and heaving, unless 
in conditions of extreme dilatation, when it is wavy and indefinite. Occa- 
sionally two or three interspaces between the nipple line and sternum will 
be depressed with the systole as a result of atmospheric pressure. Percus- 
sion shows a greater increase in the area of heart dulness than is found in 
any other valvular lesion. It extends chiefly downward and to the left. 

Auscultation. — A murmur is heard during the diastole of the ventricles 
at the base of the heart and propagated down the sternum. It may be 
feeble or inaudible at the aortic cartilage, and is usually heard best at 
midsternum opposite the third costal cartilage or along the right border 
of the sternum as low as the ensiform cartilage. It is usually soft, blowing 
in quality, and is prolonged, or " long drawn," as the phrase is. It is pro- 
duced by the reflux of blood into the ventricle. The second sound may 
be well heard or it may be replaced by the murmur. When the arch is 
dilated the second sound may have a ringing metallic or booming quality. 

The first sound may be clear at the base; more commonly there is a 
soft, short systolic murmur. In the arterio-sclerotic group the systolic 
bruit is, as a rule, short and soft, while in the endocarditic group, in which 
the valve segments are united and often covered with calcified vegetations 
and excrescences, the systolic murmur is rough and may be accompanied 
by a thrill. 

At the apex, or toward it, the diastolic murmur may be faintly heard 
propagated from the base. With full compensation the first sound is usually 
clear at the apex; with dilatation there is a loud systolic murmur of relative 
mitral insufficiency, which may disappear under observation as the dilata- 
tion lessens. 

A second murmur at the apex, probably produced at the mitral orifice, 
is not uncommon. Attention was called to tin's by the laic Austin Flint, 
and the murmur usually goes by his name. It is of a rumbling, echoing 
character, occurring in the middle or latter part of diastole, usually pre- 



714 



DISEASES OF THE CIRCULATORY SYSTEM. 



systolic in time, and limited to the apex region. It is similar to, though 
less intense than, the louder presystolic murmurs of mitral stenosis, and is 
often associated with a palpable thrill. It is probably caused by the im- 
pinging of the regurgitant current from the aortic orifice on the large, 
anterior flap of the mitral valve, so as to cause interference with the en- 
trance of blood at the time of auricular contraction. The condition is 
thus essentially the same as in a moderate mitral stenosis. This late dias- 
tolic echoing or rumbling murmur is present in about half of the cases 
of uncomplicated aortic insufficiency. It is very variable, disappearing and 
reappearing again without apparent cause. The sharp, valvular first sound 
and abrupt systolic shock, so common in true mitral stenosis, are rarely 
present, while the pulse is characteristic of uncomplicated aortic insuffi- 
ciency. 

Arteries. — The examination of the arteries in aortic insufficiency is of 
great value. Visible pulsation is more commonly seen in the peripheral 
vessels in this than in any other condition. The carotids may be seen to 
throb forcibly, the temporals to dilate, and the brachials and radials to 
expand with each heart-beat. With the ophthalmoscope the retinal arteries 
are seen to pulsate. Not only is the pulsation evident, but the character- 
istic jerking quality is apparent. In the throat the throbbing carotids may 
lead to the diagnosis of aneurism. In many cases the pulsation can be seen 
in the suprasternal notch, and prominent, forcibly-throbbing vessels be- 
neath the right sterno-mastoid muscle. The abdominal aorta may lift the 
epigastrium with each systole. To be mentioned with this is the capillary 
pulse, met very often in aortic insufficiency, and best seen in the finger-nails 
or by drawing a line upon the forehead, when the margin of hyperemia on 
either side alternately blushes and pales. In extreme grades the face or 
the hand may blush visibly at each systole. It is met with also in profound 
anaemia, occasionally in neurasthenia, and in health in conditions of great 
relaxation of the peripheral arteries. Pulsation may also be present in the 
peripheral veins. On palpation the characteristic water-hammer or Corri- 
gan pulse is felt. In the majority of instances the pulse wave strikes the 
finger forcibly with a quick jerking impulse, and immediately recedes or 
collapses. The characters of this are sometimes best appreciated by grasp- 
ing the arm above the wrist and holding it up. Moreover, the pulse of 
aortic regurgitation is usually retarded or delayed — i. e., there is an appre- 
ciable interval between the beat of the heart and the pulsation in the radial 
artery, which varies according to the extent of the incompetence. On aus- 
cultation a double murmur may be heard in the carotids and subclavians 
when it is present at the aortic orifice. Occasionally in the carotid the 
second sound is distinctly audible when absent at the aortic cartilage. 
Indeed, according to Broadbent, it is at the carotid that we must listen 
for the second aortic sound, for when heard it indicates that the regurgi- 
tation is small in amount, and is consequently a very favorable prognostic 
element. In the femoral artery a double murmur also may be heard some- 
times, as pointed out by Duroziez. 

Aortic insufficiency may for years be fully compensated. Persons do 
not necessarily suffer any inconvenience, and the condition is often found 



CHEONIC VALVULAR DISEASE. 



715 



accidentally. So long as the hypertrophy just equalizes the valvular de- 
fect there may be no symptoms and the individual may even take moder- 
ately heavy exercise without experiencing sensations of distress about the 
heart. The cases which last the longest are those in which the insufficiency 
follows endocarditis and is not a part of a general arterio-sclerosis. The 
age of the patient too, at the time of onset, is a most important considera- 
tion, as in youth the lesion is not often from sclerosis, and the coronary 
arteries are unaffected. Coexistent lesions of the mitral valves tend early to 
disturb the compensation. Pure aortic insufficiency is consistent with years 
of average health and with a tolerably active life. I know several physi- 
cians with aortic insufficiency who have been able to carry on for years large 
and somewhat onerous practices. One of them since the establishment 
of insufficiency has passed successfully through two attacks of acute rheu- 
matism. 

With the onset of myocardial changes, with increasing degeneration of 
the arteries, particularly with a progressive sclerosis of the arch and in- 
volvement of the orifices of the coronary arteries, the compensation becomes 
disturbed. In advanced cases the changes about the aortic ring may be 
associated with alterations in the cardiac nerves and ganglia, and so intro- 
duce an important factor. 

3. Aortic Stenosis. 

Narrowing or stricture of the aortic orifice is not nearly so common as 
insufficiency. The two conditions, as already stated, may occur together, 
however, and probably in almost every case of stenosis there is some leakage. 

Etiology and Morbid Anatomy. — In the milder grades there is 
adhesion between the segments, which are so stiffened that during systole 
they cannot be pressed back against the aortic wall. The process of cohe- 
sion between the segments may go on without great thickening, and pro- 
duce a condition in which the orifice is guarded by a comparatively thin 
membrane, on the aortic face of which may be seen the primitive raphes 
separating the sinuses of Valsalva. In some instances this membrane is 
so thin and presents so few traces of atheromatous or sclerotic changes that 
the condition looks as if it had originated during foetal life. More com- 
monly the valve segments are thickened and rigid, and have a cartilaginous 
hardness. In advanced cases they may be represented by stiff, calcified 
masses obstructing the orifice, through which a circular or slit-like passage 
can be seen. The older the patient the more likely it is that the valves 
will be rigid and calcified. 

We may speak of a relative stenosis of the aortic orifice when with nor- 
mal valves and ring the aorta immediately beyond is greatly dilated. A 
stenosis due to involvement of the aortic ring in sclerotic and calcareous 
changes without lesion of the valves is referred to by some authors. I have 
never met with an instance of this kind. A subvalvular stenosis, the result 
of endocarditis in the mitro-sigmoidean sinus, usually occurs as the result of 
foetal endocarditis. In comparison with aortic insufficiency, stenosis is a 
rare disease. It is usually met with at a more advanced period of life than 



716 DISEASES OF THE CIRCULATORY SYSTEM. 

insufficiency, and the most typical cases of it are found associated with 
extensive calcareous changes in the arterial system in old men. 

When gradually produced and when there is not much insufficiency 
the dilatation of the left ventricle may be slight, though I think that in 
all cases it does occur. The walls of the ventricles become hypertrophied, 
and we see in this condition the most typical, instances of what is called 
concentric hypertrophy, in which, without much, if any, enlargement of 
the cavity, the walls are greatly thickened, in contradistinction to the so- 
called eccentric hypertrophy, in which, with the increase in the thickness 
of the walls, the chamber itself is greatly dilated. There may be no changes 
in the other cardiac cavities if compensation is well maintained; but with 
its failure come dilatation, impeded auricular discharge, pulmonary con- 
gestion, and increased work for the right heart. The arterial changes are, 
as a rule, not so marked as in aortic insufficiency, for the walls have not 
to withstand the impulse of a greatly increased blood-wave with each sys- 
tole. On the contrary, the amount of blood propelled through the narrow 
orifice may be smaller than normal, though when compensation is fully 
established the pulse-wave may be of medium volume. 

Symptoms. — Physical Signs. — Inspection may fail to reveal any area 
of cardiac impulse. Particularly is this the case in old men with rigid 
chest walls and large emphysematous lungs. Under these circumstances 
there may be a high grade of hypertrophy without any visible impulse. 
Even when the apex beat is visible, it may be, as Traube pointed out, feeble 
and indefinite. In many cases the apex is seen displaced downward and 
outward, and the impulse looks strong and forcible. 

Palpation reveals in many cases a thrill at the base of the heart of 
maximum force in the aortic region. With no other condition do we meet 
with thrills of greater intensity. The apex beat may not be palpable under 
the conditions above mentioned, or there may be a slow, heaving, forcible 
impulse. 

Percussion never gives the same wide area of dulness as in aortic in- 
sufficiency. The extent of it depends largely on the state of the lungs, 
whether emphysematous or not. 

Auscultation. — A rough systolic murmur, of maximum intensity at the 
aortic cartilage, and propagated into the great vessels, is the most constant 
physical sign in aortic stenosis. One of the last lessons learned by the stu- 
dent of physical diagnosis is to recognize the fact that a systolic murmur at 
the aortic area is only in comparatively rare cases produced by decided nar- 
rowing of the aortic orifice. Roughening of the valves, or of the intima of 
the aorta, and hsemic states are much more frequent causes. In aortic steno- 
sis the murmur often has a much harsher quality, is louder, and is more fre- 
quently musical than in the conditions just mentioned. When compensation 
fails and the ventricle is dilated and feeble, the murmur may be soft and dis- 
tant. The second sound is rarely heard at the aortic cartilage, owing to the 
thickening and stiffness of the valve. A diastolic murmur is not uncommon, 
but in many cases it can not be heard. Occasionally, as noted by W. H. 
Dickinson, there is a musical murmur of greatest intensity in the region of 
the apex, due probably to a slight regurgitation at high pressure through 



CHRONIC VALVULAR DISEASE. 



717 



the mitral valves. The pulse in pure aortic stenosis is small, usually of 
good tension, well sustained, regular, and perhaps slower than normal. 

The condition may be latent for an indefinite period, as long as the 
hypertrophy is maintained. Early symptoms are those du e to defective 
blood-supply to the brain, dizziness, and fainting. Palpitation, pain about 
the heart, and anginal symptoms are not so. marked as in insufficiency. 
With degeneration of the heart-muscle and dilatation relative insufficiency 
of the mitral valve is established, and the patient may present all the fea- 
tures of engorgement in the lesser and systemic circulations, with dyspnoea, 
cough, rusty expectoration, and the signs of anasarca in the lower part of 
the body. Many of the cases in old people, without presenting any dropsy, 
""Have symptoms pointing rather to general arterial disease. Cheyne-Stokes 
breathing is not uncommon with or without signs of uraemia. 

Diagnosis. — With an extremely rough or musical murmur of maxi- 
mum intensity at the aortic region and signs of hypertrophy of the left 
ventricle, a thrill, and especially a hard, slow pulse of moderate volume and 
fairly good tension, which in a sphygmographic tracing gives a curve of slow 
rise, a broad, well-sustained summit and slow decline, a diagnosis of aortic 
stenosis can be made with some degree of probability, particularly if the 
subject is an old man. Mistakes are common, however, and a roughened 
or calcified valve segment, or, in some instances, a very roughened and 
prominent calcified plate in the aorta, and hypertrophy associated with 
renal disease, may produce similar symptoms. 

Let me repeat that a murmur of maximum intensity at the aortic car- 
tilage is of no importance in itself as a diagnostic sign of stenosis. Rough- 
ening of the valve, sclerosis of the intima of the arch, and anaemia are con- 
ditions more frequently associated with a systolic murmur in this region. 
Seldom is there difficulty in distinguishing the murmur due to anaemia, 
since it is rarely so intense and is not associated wth thrill or with marked 
hypertrophy of the left ventricle. In aortic insufficiency a systolic mur- 
mur is usually present, but lias neither the intensity nor the musical qual- 
ity, nor is it accompanied with a thrill. With roughening and dilatation 
of the ascending aorta the murmur may be very harsh or musical; but the 
existence of a second sound, accentuated and ringing in quality, is usually 
sufficient to differentiate this condition. 

4. Mitral Incompetency. 

Etiology. — Insufficiency of the mitral valve ensues: (a) From 
changes in the segments whereby they are contracted and shortened, usu- 
ally combined with changes in the chordae tendineae, or with more or less 
narrowing of the orifice, (b) As a result of changes in the muscular walls 
of the ventricle, either dilatation, so that the valve segments fail to close 
an enlarged orifice, or changes in the muscular substance, so that -the seg- 
ments are imperfectly coapted during the systole — muscular incompetency. 
The common lesions producing insufficiency result from endocarditis, which 
causes a gradual thickening at the edges of the valves, contraction of the 
chordae tendineae, and union of the edges of the segments, so that in a 



718 



DISEASES OF THE CIRCULATORY SYSTEM. 



majority of the instances there is not only insufficienc} 7 , but some grade of 
narrowing as well. Except in children, we rarely see the mitral leaflets 
curled and puckered without narrowing of the orifice. Calcareous plates 
at the base of the valve may prevent perfect closure of one of the segments. 
In long-standing cases the entire mitral structures are converted into a firm 
calcareous ring. From this valvular insufficiency the other condition of 
muscular incompetency must be carefully distinguished. It is met with 
in all conditions of extreme dilatation of the left ventricle, and also in 
weakening of the muscles in prolonged fevers and in anaemia. 

Morbid Anatomy. — The effects of incompetency of the mitral seg- 
ment upon the heart and circulation are as follows: (a) The imperfect 
closure allows a certain amount of blood to regurgitate from the ventricle 
into the auricle, so that at the end of auricular diastole this chamber con- 
tains not only the blood which it has received from the lungs, but also that 
which has regurgitated from the left ventricle. This necessitates dilata- 
tion, and, as increased work is thrown upon it in expelling the augmented 
contents, hypertrophy as well. 

(b) With each systole of the left auricle a larger volume of blood is 
forced into the left ventricle, which also dilates and subsequently becomes 
hypertrophied. 

(c) During the diastole of the left auricle, as blood is regurgitated into 
it from the left ventricle, the pulmonary veins are less readily emptied. 
In consequence the right ventricle expels its contents less freety, and in 
turn becomes dilated and hypertrophied. 

(d) Finally, the right auricle also is involved, its chamber is enlarged, 
and its Avails are increased in thickness. 

(e) The effect upon the pulmonary vessels is to produce dilatation both 
of the arteries and veins — often in long-standing cases, atheromatous 
changes; the capillaries are distended, and ultimately the condition of 
brown induration is produced. Perfect compensation may be effected, 
chiefly through the hypertrophy of both ventricles, and the effect upon 
the peripheral circulation may not be manifested for years, as a normal 
volume of blood is discharged from the left heart at each systole. The 
time comes, however, when, owing either to increase in the grade of the 
incompetency or to failure of the compensation, the left ventricle is unable 
to send out its normal volume into the aorta. Then there is overfilling of 
the left auricle, engorgement in the lesser circulation, embarrassed action 
of the right heart, and congestion in the systemic veins. For years this 
somewhat congested condition may be limited to the lesser circulation, but 
finally the right auricle becomes dilated, the tricuspid valves incompetent, 
and the systemic veins are engorged. This gradually leads to the condi- 
tion of cyanotic induration in the viscera and, when extreme, to dropsical 
effusion. 

Muscular incompetency, due to impaired nutrition of the mitral and 
papillary muscles, is rarely followed by such perfect compensation. There 
may be in acute destruction of the aortic segments an acute dilatation of 
the left ventricle with relative incompetency of the mitral segments, great 
dilatation of the left auricle, and intense engorgement of the lungs, under 



CHRONIC VALVULAR DISEASE. 



719 



which circumstances profuse haemorrhage may result. In these cases there 
is little chance for the establishment of compensation. In cases of hyper- 
trophy and dilatation of the heart, without valvular lesions, but associated 
with heavy work and alcohol, the insufficiency of the mitral valve may be 
extreme and lead to great pulmonary congestion, engorgement of the sys- 
temic veins, and a condition of cardiac dropsy, which cannot be distin- 
guished by any feature from that of mitral incompetency due to lesion of 
the valve itself. In chronic Bright's disease the hypertrophy of the left 
ventricle may gradually fail, leading, in the later stages, to relative in- 
sufficiency of the mitral valve, and the production of a condition of pul- 
monary and systemic congestion, similar to that induced by the most ex- 
treme grade of lesion of the valve itself. Adherent pericardium, especially 
in children, may lead to like results. 

Symptoms. — During the development of the lesion, unless the in- 
competency comes on acutely in consequence of rupture of the valve seg- 
ment or of ulceration, the compensatory changes go hand in hand with the 
defect, and there are no subjective symptoms. So, also, in the stage of 
perfect compensation, there may be the most extreme grade of mitral 
insufficiency with enormous hypertrophy of the heart, yet the patient may 
not be aware of the existence of heart trouble, and may suffer no incon- 
venience except perhaps a little shortness of breath on exertion or on going- 
upstairs. It is only when from any cause the compensation has not been 
perfectly effected, or, having been so, is broken abruptly or gradually, that 
the patients begin to be troubled. The symptoms may be divided into two 
groups: 

(a) The minor manifestations while compensation is still good. Pa- 
tients with extreme incompetency often have a congested appearance of 
the face, the lips and ears have a bluish tint, and the venules on the cheeks 
may be enlarged — signs in many cases very suggestive. In long-standing- 
cases, particularly in children, the fingers may be clubbed, and there is 
shortness of breath on exertion. This is one of the most constant features 
in mitral insufficiency, and may exist for years, even when the compensa- 
tion is perfect. Owing to the somewhat congested condition of the lungs 
these patients have a tendency to attacks of bronchitis or haemoptysis. 
There may also be palpitation of the heart. As a rule, however, in well- 
balanced lesions in adults, this period of full compensation or latent stage 
is not associated with symptoms which call the attention to an affection 
of the heart, and with care the patient may reach old age in comparative 
comfort without being compelled to curtail seriously his pleasures or his 
work. 

(b) Sooner or later comes a period of disturbed or broken compensa- 
tion, in which the most intense symptoms are those of venous engorgement. 
There are palpitation, weak, irregular action of the heart, and signs of 
dilatation. Dyspnoea is an especial feature, and there may be cough. A 
distressing symptom is the cardiac "sleep-start," in which, just as the pa- 
tient falls asleep, he wakes gasping and feeling as if the heart was stopping. 
There is usually a slight cyanosis, and even a jaundiced tint to the skin. 
The most marked symptoms, however, are those of venous stasis. The 

45 



720 



DISEASES OF THE CIRCULATORY SYSTEM. 



overfilling of the pulmonary vessels accounts in part for the dyspnoea. 
There is cough, often with bloody or watery expectoration, and the alveolar 
epithelium containing brown pigment-grains is abundant. Dropsical effu- 
sion usually sets in, beginning in the feet and extending to the body and 
the serous sacs. Eight-sided hydrothorax may recur and require repeated 
tapping. The liver is enlarged, and there are signs of portal congestion. 
The urine is usually scanty and albuminous, and contains tube-casts and 
sometimes blood-corpuscles. With judicious treatment the compensation 
may be restored and all the serious symptoms may pass away. Patients 
usually have recurring attacks of this kind, and die of a general dropsy; 
or there is progressive dilatation of the heart, and death from asystole. 
Sudden death in these cases is rare. 

Physical Signs. — Inspection. — In children the prsecordia may bulge and 
there may be a large area of visible pulsation. The apex beat is to the left 
of the nipple, in some cases in the sixth interspace, in the anterior axillary 
line. There may be a wavy impulse in the cervical veins which are often 
full, particularly when the patient is recumbent. 

Palpation. — A thrill is rare; when present it is felt at the apex, often 
in a limited area. The force of the impulse may depend largely upon the 
stage in which the case is examined. In full compensation it is forcible 
and heaving; when the compensation is disturbed, usually wavy and feeble. 

Percussion. — The dulness is increased, particularly in a lateral direction. 
There is no disease of the valves which produces, in long-standing cases, 
a more extensive transverse area of heart dulness. It does not extend so 
much upward along the left margin of the sternum as beyond the right 
margin and to the left of the nipple line. 

Auscultation. — At the apex there is a systolic murmur which wholly 
or partly obliterates the first sound. It is loudest here, and has a blowing, 
sometimes musical character, particularly toward the latter part. The 
murmur is transmitted to the axilla and may be heard at the back, in some 
instances over the entire chest. There are cases in which, as pointed out 
by Naunyn, the murmur is heard best along the left border of the sternum. 
Usually in diastole at the apex the loudly transmitted second sound may 
be heard. Occasionally there is also a soft, sometimes a rough or rumbling 
presystolic murmur. As a rule, in cases of extreme mitral insufficiency 
from valvular lesion with great hypertrophy of both ventricles, there is 
heard only a loud blowing murmur during systole. A murmur of mitral 
insufficiency may vary a great deal according to the position of the patient. 
It may be present in the recumbent and absent in the erect posture. In 
cases of dilatation, particularly when dropsy is present, there may be heard 
at the ensiform cartilage and in the lower sternal region a soft systolic 
murmur due to tricuspid regurgitation. An important sign on ausculta- 
tion is the accentuated pulmonary second sound. This is heard to the left 
of the sternum in the second interspace, or over the third left costal car- 
tilage. 

The pulse in mitral insufficiency, during the period of full compensa- 
tion, may be full and regular, often of low tension. Usually with the first 
onset of the s}nmptoms the pulse becomes irregular, a feature which then 



CHRONIC VALVULAR DISEASE. 



721 



dominates the ease throughout. There may be no two beats of equal force 
or volume. Often after the disappearance of the symptoms of failure of 
compensation the irregularity of the pulse persists. 

The three important physical signs then of mitral regurgitation are: 
(a) Systolic murmur of maximum intensity at the apex, which is propa- 
gated to the axilla and heard at the angle of the scapula; (b) accentuation 
of the pulmonary second sound; (c) evidence of enlargement of the heart, 
particularly the increase in the transverse diameter, due to hypertrophy 
of both right and left ventricles. 

Diagnosis. — There is rarely any difficulty in the diagnosis of mitral 
insufficiency. The physical signs just referred to are quite characteristic 
and distinctive. Two points are to be borne in mind. First, a murmur, 
systolic in character, and of maximum intensity at the apex, and propa- 
gated even to the axilla, does not necessarily indicate incompetency of the 
mitral valve. There is heard in this region a large group of what are 
termed accidental murmurs, the precise nature of which is still doubtful. 
They are probably formed, however, in the ventricle, and are not associated 
with hypertrophy, or accentuation of pulmonary second sound. 

Second, it is not always possible to say whether the insufficiency is due 
to lesion of the valve segment or to dilatation of the mitral ring and rela- 
tive incompetency. Here neither the character of the murmur, the propa- 
gation, the accentuation of the pulmonary second sound, nor the hyper- 
trophy assists in the differentiation. The history is sometimes of greater 
value in this matter than the physical examination. The cases most likely 
to lead to error are those of the so-called idiopathic dilatation and hyper- 
trophy of the heart (in which the systolic murmur may be of the greatest 
intensity), and the instances of arterio-sclerosis with dilated heart. Balfour 
and others, however, maintain that organic disease of the mitral leaflets 
sufficient to produce incompetency is always accompanied with a certain 
degree of narrowing of the orifice, so that the only unequivocal proof of the 
actual disease of the mitral valve is the presence of a presystolic murmur. 

5. Mitkal Stenosis. 

Etiology. — Narrowing of the mitral orifice is usually the result of 
valvular endocarditis occurring in the earlier years of life; very rarely it 
is congenital. It is very much more common in women than in men — in 
63 of 80 cases noted by Duckworth, while in 4,791 autopsies at Guy's Hos- 
pital during ten years there were 196 cases, of which 107 were females and 
89 males (Samways). This is not easy to explain, but there are at least two 
factors to be considered. Rheumatism prevails more in girls than in boys 
and, as is well known, endocarditis of the mitral valve is more common 
in rheumatism. Chorea, also, as suggested by Barlow, has an important 
influence, occurring more frequently in girls and being often associated 
with endocarditis. Of 140 cases of chorea which I examined at a period 
more than two years subsequent to the attack, 72 had signs of organic 
heart-disease, among which were 24 instances with the physical signs of 
mitral stenosis. Anaemia and chlorosis, which are prevalent in girls, have 



722 



DISEASES OF THE CIRCULATORY SYSTEM. 



been regarded as possible factors. In a surprising number of eases no recog- 
nizable etiological factor can be discovered. This has been regarded by 
some writers as favoring the view that many cases are of congenital origin; 
but it is not improbable that with any of the febrile affections of childhood 
endocarditis may be associated. Whooping-cough, too, with its terrible 
strain on the heart-valves, may be accountable for certain cases. Con- 
genital affections of the mitral valve are notoriously rare. While met with 
at all ages, stenosis is certainly more frequent in young persons. 

Morbid Anatomy. — In a majority of instances with the stenosis 
there is some incompetency; indeed, Balfour maintains that we never find 
mitral stenosis without some degree of regurgitation. The narrowing re- 
sults from thickening and contraction of the tissues of the ring, of the valve 
segments, and of the chordae tendineae. The condition varies a good deal 
according to the amount of atheromatous change. In many cases the cur- 
tains are so welded together and the whole valvular region so thickened that 
the orifice is reduced to a mere chink — Corrigan's button-hole contraction. 
In other cases the curtains are not much thickened, but narrowing has 
resulted from gradual adhesion at the edges, and thickening of the chordae 
tendineae, so that from the auricle it looks cone-like — the so-called funnel- 
shaped variety of stenosis. The instances in which the valve segments are 
very slightly deformed, but in which the orifice is considerably narrowed, 
are regarded by some as possibly of congenital origin. Occasionally the 
curtains are in great part free from disease, but the narrowing results from 
large calcareous masses, which project into them from the ring. The in- 
volvement of the chordae tendineae is usually extreme, and the papillary 
muscles may be inserted directly upon the valve. In moderate grades of 
constriction the orifice will admit the tip of the index-finger; in more 
extreme forms, the tip of the little finger; and occasionally one meets with 
a specimen in which the orifice seems almost obliterated, as in a case which 
came under my notice, which only admitted a medium-sized Bowman's 
probe. 

The heart in mitral stenosis is not greatly enlarged, rarely weighing 
more than 14 or 15 ounces. Occasionally, in an elderly person, it may 
seem only slightly, if at all, enlarged, and again there are instances in which 
the weight may reach as much as 20 ounces. The left ventricle is usually 
small, and may look very small in comparison with the right ventricle, 
which forms the greater portion of the apex. In cases in which with the 
narrowing there is very considerable incompetency the left ventricle may 
be moderately dilated and hypertrophied. 

These changes gradually induced are associated with secondary altera- 
tions of great importance in the heart. The left auricle discharges its blood 
with greater difficulty and in consequence dilates, and its walls reach three 
or four times their normal thickness. Although the auricle is by structure 
unfitted to compensate an extreme lesion, the probability is that for some 
time during the gradual production of stenosis, the increasing muscular 
power of the walls is sufficient to counterbalance the defect. Samways 
found in 36 cases of well-marked stenosis the auricle hypertrophied in 26, 
dilatation coexisting in 14. Eventually the tension is increased in the pul- 



CHRONIC VALVULAR DISEASE, 



Y23 



monary circulation, owing to impeded outflow from the veins. To overcome 
this the right ventricle undergoes dilatation and hypertrophy, and upon this 
chamber falls the work of equalizing the circulation. Relative incompetency 
of the tricuspid and congestion of the systemic veins at last supervene. 

It is not uncommon at the examination to find white thrombi in the 
appendix of the left auricle. Occasionally a large part of the auricle is 
occupied by an ante-mortem thrombus. Still more rarely the remarkable 
ball thrombus is found, in which a globular concretion, varying in size from 
a walnut to a small egg, lies free in the auricle, two examples of which have 
come under my observation (see W. H. Welch, art. Thrombosis, Allbntt's 
System). 

Symptoms. — Physical Signs. — Inspection. — In children the lower 
sternum and the fifth and sixth left costal cartilages are often prominent, 
owing to hypertrophy of the right ventricle. The apex beat may be ill- 
defined. Usually, it is not dislocated far beyond the nipple line, and the 
chief impulse is over the lower sternum and adjacent costal cartilages. 
Often in thin-chested persons there is pulsation in the third and fourth 
left interspaces close to the sternum. • When compensation fails, the pre- 
cordial impulse is much feebler, and in the veins of the neck there may be 
marked systolic regurgitation. 

Palpation reveals in a majority of the cases a characteristic, well-defined 
fremitus or thrill, which is best felt, as a rule, in the fourth or fifth inter- 
space within the nipple line. It is of a rough, grating quality, often pecul- 
iarly limited in area, most marked during expiration, and can be felt to 
terminate in a sharp, sudden shock, synchronous with the impulse. This 
most characteristic of physical signs is pathognomonic of narrowing of the 
mitral orifice, and is perhaps the only instance in which the diagnosis of 
a valvular lesion can be made by palpation alone. The cardiac impulse is 
felt most forcibly in the lower sternum and in the fourth and fifth left in- 
terspaces. The impulse is felt very high in the third and fourth interspaces, 
or in rare cases even in the second, and it has been thought that in the 
latter interspace the impulse is due to pulsation of the auricle. It is always 
the impulse of the conus arteriosus of the right ventricle; even in the most 
extreme grades of mitral stenosis, there is never such tilting forward of the 
auricle or its appendix as would enable it to produce an impression on the 
chest wall. 

Percussion gives an increase in the cardiac dulness to the right of the 
sternum and along the left margin; not usually a great increase beyond 
the nipple line, except in extreme cases, when the transverse dulness may 
reach from 5 cm. beyond the right margin of the sternum to 10 cm. beyond 
the nipple line. 

Auscultation. — In the mitral area, usually to the inner side of the apex 
beat and often in a very limited region, is heard a rough, vibratory or purr- 
ing murmur, which terminates abruptly in the first sound. By combining 
palpation and auscultation the purring murmur is found to be synchro- 
nous with the thrill and the loud shock with the first sound. This is the 
presystolic murmur, about the time and mode of production of which so 
much discussion has occurred. I hold with those who regard it as occur- 



724: 



DISEASES OF THE CIRCULATORY SYSTEM. 



ring during the auricular systole. In whatever way produced, it remains 
one of the most distinctive and characteristic of murmurs and its presence 
is positively indicative of narrowing of the mitral orifice. The sole excep- 
tion to this statement is the Flint murmur already referred to in aortic 
incompetency. Once, in a case of enormous enlargement of the spleen, 
with dropsy, in which the heart was greatly pushed up, I heard a presystolic 
murmur of rough quality, and the mitral valves were found post mortem 
to be normal. The presystolic murmur may occupy the entire period of the 
diastole, or the middle or only the latter half, corresponding to the auricu- 
lar systole. The difference may sometimes be noted between the first and 
second portions of the murmur, when it occupies the entire time. Often 
there is a peculiar rumbling or echoing quality, which in some instances 
is very limited and may be heard only over a single bell-space of the stetho- 
scope. A systolic murmur may be heard at the apex or along the left sternal 
border, often of extreme softness and audible only when the breath is held. 
Sometimes the systolic murmur is loud and distinct and is transmitted to 
the axilla. The second sound in the second left interspace is loudly accentu- 
ated, sometimes reduplicated. It may be transmitted far to the left and 
be heard with great clearness beyond the apex. In uncomplicated cases 
of mitral stenosis there are usually no murmurs audible at the aortic region, 
at which spot the second sound is less intense than at the pulmonary area. 
In the lower sternum and to the right a tricuspid murmur is sometimes 
heard in advanced cases. Other points to be noted are the following: The 
unusually sharp, clear first sound which follows the presystolic murmur, 
the cause of which is by no means easy to explain. It can scarcely be a 
valvular sound produced chiefly at the mitral orifice, since it may be heard 
with great intensity in cases in which the valves are rigid and calcified. 
It has been suggested by A. E. Sansom and others that it is a loud 
" snap " of the tricuspid valves caused by the powerful contraction of the 
greatly hypertrophied right ventricle. Broadbent's explanation is as fol- 
lows: " Owing to the narrowing of the mitral orifice there is not time in 
the diastolic interval for a sufficient amount of blood to flow into the left 
ventricle to completely fill it. At the commencement of systole, therefore, 
the ventricular, cavity is not fully distended with blood, so that the mus- 
cular walls at the first moment of their contraction meet with no resist- 
ance; then closing down rapidly, they are suddenly brought up and made 
tense as they encounter the contained blood. This sudden tension and 
abbreviated systole may thus account for the short first sound." The 
valvular sound may be audible at a distance, as one sits at the bedside of 
the patient (Graves). 

These physical signs, it is to be borne in mind, are characteristic only 
of the stage in which compensation is maintained. Finally there comes a 
period in which, with rupture of compensation, the presystolic murmur 
disappears and there is heard in the apex region a sharp first sound, or 
sometimes a gallop rhythm. The marked systolic shock may be present 
after the disappearance of the thrill and the characteristic murmur. Under 
treatment, with gradual recovery of compensation, probably with increas- 
ing vigor of contraction of the right ventricle and left auricle, the pre- 



CHRONIC VALVULAR DISEASE. 



725 



systolic murmur reappears. In cases seen at this stage of the disease the 
nature of the valve lesion may be entirely overlooked. 

Stenosis of the mitral valve may for years be efficiently compensated 
by the hypertrophy of the right ventricle. Many persons with the char- 
acteristic physical signs of this lesion present no symptoms. They may 
for years perhaps be short of breath on going upstairs, but are able to pass 
through the ordinary duties of life without discomfort. The pulse is 
smaller in volume than normal, and very often irregular. A special 
danger of this stage is the recurring endocarditis. Vegetations may be 
whipped off into the circulation and, blocking a cerebral vessel, may cause 
hemiplegia or aphasia, or both. This, unfortunately, is not an uncommon 
sequence in women. Patients with mitral stenosis may survive this acci- 
dent for an indefinite period. A woman, above seventy years of age, died 
in one of my wards at the Philadelphia Hospital, who had been in the 
almshouse, hemiplegic, for more than thirty years. The heart presented 
an extreme grade of mitral stenosis which had probably existed at the time 
of the hemiplegic attack. 

Pressure of the enlarged auricle on the left recurrent laryngeal nerve, 
causing paralysis of the vocal cord on the corresponding side, has been 
described by Ortner and by Herrick. I have met with two instances. It 
is a point to be borne in mind, as the diagnosis of aneurism of the arch of 
the aorta may be made. 

Failure of compensation brings in its train the group of symptoms 
which have been discussed under mitral insufficiency. Briefly, enumerated 
they are: Eapid and irregular action of the heart, shortness of breath, 
cough, signs of pulmonary engorgement, and very frequently haemoptysis. 
Attacks of this kind may recur for years. Bronchitis or a febrile attack 
may cause shortness of breath or slight blueness. Inflammatory affections 
of the lungs or pleura seriously disturb the right heart, and these patients 
stand pneumonia very badly. Many, perhaps a majority of cases of mitral 
stenosis, do not have dropsy. The liver may be greatly enlarged, and in 
the late stages ascites is not uncommon, particularly in children. General 
anasarca is most frequently met with in those cases in which there is sec- 
ondary narrowing of the tricuspid orifice (Broadbent). 

6. Tricuspid Valve Disease. 

(a) Tricuspid Regurgitation. — Occasionally this results from acute or 
chronic endocarditis with puckering; more commonly the condition is one 
of relative insufficiency, and is secondary to lesions of the valves on the left 
side, particularly of the mitral. It is met with also in all conditions of the 
lungs which cause obstruction to the circulation, such as cirrhosis and 
emphysema, particularly in combination with chronic bronchitis. The 
symptoms are those of obstruction in the lesser circulation with venous 
congestion in the systemic veins, such as has already been described in con- 
nection with mitral insufficiency. The signs of this condition are: 

(1) Systolic regurgitation of the blood into the right auricle and the 
transmission of the pulse-wave into the veins of the neck. If the regurgi- 



726 



DISEASES OF THE CIRCULATORY SYSTEM. 



tation is slight or the contraction of the ventricle is feeble there may be 
no venous throbbing, but in other cases there is marked systolic pulsation 
in the cervical veins. That in the right jugular is more forcible than that 
in the left. It may be seen both in the internal and the external vein, 
particularly in the latter. Marked pulsation in these veins occurs only 
when the valves guarding them become incompetent. Slight oscillations 
are by no means uncommon, even when the valves are intact. The dis- 
tention is sometimes enormous, particularly in the act of coughing, when 
the right jugular at the root of the neck may stand out, forming 
an extraordinary prominent ovoid mass. Occasionally the regurgitant 
pulse-wave may be widely transmitted and be seen in the subclavian and 
axillary veins, and even in the subcutaneous veins over the shoulder, 
or, as in a case recently under observation, in the superficial mammary 
veins. 

Regurgitant pulsation through the tricuspid orifice may be transmitted 
to the inferior cava, and so to the hepatic veins, causing a systolic disten- 
tion of the liver. This is best appreciated by bimanual palpation, placing 
one hand over the fifth and sixth costal cartilages and the other in the 
lateral region of the liver in the mid-axillary line. The rhythmical ex- 
pansile pulsation may be readily distinguished, as a rule, from the systolic 
depression of the liver due to communicated pulsation from the left ven- 
tricle. 

(2) The second important sign of tricuspid regurgitation is the occur- 
rence of a systolic murmur of maximum intensity in the lower sternum. 
It is usually a soft, low murmur, often to be distinguished from a coexist- 
ing mitral murmur by differences in quality and pitch, and may be heard 
to the right as far as the axilla. Sometimes it is very limited in its distri- 
bution. 

Together these two signs positively indicate tricuspid regurgitation. 
In addition, the percussion usually shows increase in the area of dulness 
to the right of the sternum, and the impulse in the lower sternal region is 
forcible. In the great majority of cases the symptoms are those of the 
associated lesions. In cirrhosis of the lung and in chronic emphysema the 
failure of compensation of the right ventricle with insufficiency of the tri- 
cuspid not infrequently leads either to acute asystole or to gradual failure 
with cardiac dropsy. 

(b) Tricuspid Stenosis. — This interesting condition may be either con- 
genital or acquired. The congenital cases are not uncommon, and are 
associated usually with other valvular defects which cause early death. The 
acquired form is not very infrequent. Bedford Fenwick collected 46 ob- 
servations, of which 41 were in women. Leudet * has analyzed 117 cases. 
Of 101 of these in which the ages were mentioned, 80 were in women and 
21 in men. A great majority of the cases were in adults, only 8 being 
between the ages of ten and twenty. Its rarity as an isolated condition 
may be gathered from the fact that of 114 autopsies, in 11 only was the 
lesion confined to this valve. In 21 the tricuspid, mitral, and aortic seg- 



* Paris Thesis, 1888. 



CHRONIC VALVULAR DISEASE. 



T27 



ments were involved, and in 78 the tricuspid and mitral. Practically the 
condition is almost always secondary to lesions of the left heart. 

The physical signs are sometimes characteristic. For instance, a pre- 
systolic thrill has been noted by several observers. The percussion shows 
dulness to be increased, particularly to the right of the sternum. On aus- 
cultation a presystolic murmur has been determined in certain cases, and 
is heard best at the root of the ensiform cartilage, or a little to the right 
of it. Of general symptoms, cyanosis of the face and lips is very common, 
and in the late stages, when dropsy supervenes, it is apt to be intense. The 
lesion is interesting chiefly because it forms one of the most serious com- 
plications of mitral stenosis. 

7. Pulmonary Valve Disease. 

Murmurs in the region of the pulmonary valves are extremely common; 
lesions of the valves are exceedingly rare. Balfour has well called the pul- 
monic area the region of romance. A systolic murmur is heard here under 
many conditions — (1) very often in health, in thin-chested persons, par- 
ticularly in children, during expiration and in the recumbent posture; (2) 
when the heart is acting rapidly, as in fever and after exertion; (3) it is a 
favorite situation of the cardio-respiratory murmur; (4) in anaemic states; 
and (5) as mentioned previously, the systolic murmur of mitral insufficiency 
may be transmitted along the left sternal margin. Actual lesions of the 
valves of the pulmonary artery are rare. 

(a) Stenosis is almost invariably a congenital anomaly. It constitutes 
one of the most important of the congenital cardiac affections. The valve 
segments are usually united, leaving a small, narrow orifice. In the adult 
cases occasionally occur. In Case 608 of my post-mortem records there 
was extreme stenosis in a girl of eighteen, owing to great thickening and 
adhesion of the segments, and there were also numerous vegetations. The 
orifice was only 2 mm. in diameter. The congenital lesion is commonly asso- 
ciated with patency of the ductus Botalii and imperfection of the ventricu- 
lar septum. There may also be tricuspid stenosis. 

The physical signs are extremely uncertain. There may be a systolic 
murmur with a thrill heard best to the left of the sternum in the second 
intercostal space. This murmur may be very like a murmur of aortic 
stenosis, but is not transmitted into the vessels. Naturally the pulmonary 
second sound is weak or obliterated, or may be replaced by a diastolic mur- 
mur. Usually there is hypertrophy of the right heart. 

(b) Pulmonary Insufficiency. — This rare affection is occasionally due to 
congenital malformation, particularly fusion of two of the segments. It is 
sometimes present, as Bramwell has shown, in cases of malignant endoear- 
ditis. Barie has collected 58 cases. 

The physical signs are those of regurgitation into the right ventricle, 
but, as a rule, it is difficult to differentiate the murmur from that of aortic 
insufficiency, though the maximum intensity may be in the pulmonary 
area. The absence of the vascular features of aortic insufficiency is sug- 
gestive. Both Gibson and Graham Steell have called attention to the pos- 



72S 



DISEASES OF THE CIRCULATORY SYSTEM. 



sibility of leakage through these valves in cases of great increase of pressure 
in the pulmonary artery, and to a soft diastolic murmur heard under these 
circumstances, which Steell calls " the murmur of high pressure in the 
pulmonary artery." 

• ' 8. Combined Valvular Lesions. 

These are extremely common. The mitral and aortic segments may be 
affected together; next in frequency comes the combination of mitral and 
tricuspid lesions; and then of aortic, mitral, and tricuspid. Aortic insuf- 
ficiency or aortic stenosis is more frequently combined with mitral incom- 
petency than aortic stenosis with mitral stenosis, or mitral stenosis with 
aortic insufficiency. In children the most common combination is aortic 
and mitral insufficiency. In adults, mitral insufficiency with thickening 
of the aortic valves and slight narrowing is perhaps the most common. 

The diagnosis rests upon the character of the murmurs and the state 
of the chambers as regards hypertrophy and dilatation. 

Prognosis in Valvular Disease. — The question is entirely one 
of efficient compensation. So long as this is maintained the patient may 
suffer no inconvenience, and even with the most serious forms of valve 
lesion the function of the heart may be little, if at all, disturbed. 

Practitioners who are not adepts in auscultation and feel unable to esti- 
mate the value of the various heart murmurs should remember that the 
best judgment of the conditions may be gathered from inspection and pal- 
pation. With an apex beat in the normal situation and regular in rhythm 
the auscultatory phenomena may be practically disregarded. 

As Sir Andrew Clark states, a murmur per se is of little or no moment 
in determining the prognosis' in any given case. There is a large group 
of patients who present no other symptoms than a systolic murmur heard 
over the body of the heart, or over the apex, in whom the left ventricle is 
not hypertrophied, the heart rhythm is normal, and who may not have 
had rheumatism. Indeed, the condition is accidentally discovered, often 
during examination for life insurance. I know cases of this kind which 
have persisted unchanged for more than fifteen years. Among the condi- 
tions influencing prognosis are: 

(a) Age. — Children under ten are bad subjects. Compensation is well 
effected, and they are free from many of the influences which disturb com- 
pensation in adults. The coronary arteries are healthy, and nutrition of 
the heart-muscle can be readily maintained. Yet, in spite of this, the out- 
look in cardiac lesions developing in very young children is usually bad. 
One reason is that the valve, lesion itself is apt to be rapidly progressive, 
and the limit of cardiac reserve force is in such cases early reached. There 
seems to be proportionately a greater degree of hypertrophy and dilatation. 
Among other causes of the risks of this period are to be mentioned insuf- 
ficient food in the poorer classes, the recurrence of rheumatic attacks, and 
the existence of pericardial adhesions. The outlook in a child who can be 
carefully supervised and prevented from damaging himself by overexertion 
is naturally better than in one who is constantly overtasking his muscles. 



CHRONIC VALVULAR DISEASE. 729 

The valvular lesions which develop at, or subsequent to, the period of 
puberty are more likely to be permanently and efficiently compensated. 
Sudden death from heart-disease is very rare in children. 

(b) Sex. — Women bear valve lesions, as a rule, better than men, owing 
partly to the fact that they live quieter lives, partly to the less common 
involvement of the coronary arteries, and to the greater frequency of mitral 
lesions. Pregnancy and parturition are disturbing factors, but are, I think, 
less serious than some writers would have us believe. 

(c) Valve affected. — The relative prognosis of the different valve lesions 
is very difficult to estimate. Each case must, therefore, be judged on its 
own merits. Aortic insufficiency is unquestionably the most serious; yet 
for years it may be perfectly compensated. Favorable circumstances in 
any case are the moderate grade of hypertrophy and dilatation, the absence 
of all symptoms of cardiac distress, and the absence of extensive arterio- 
sclerosis and of angina. The prognosis rests in reality with the condition 
of the coronary arteries. Eheumatic lesions of the valves, inducing insuf- 
ficiency, are less apt to be associated with endarteritis at the root of the 
aorta; and in- such cases the coronary arteries may escape for years. I 
know a physician, now about forty-three years of age, who, when sixteen, 
had his first attack of rheumatism, which involved the aortic segments. 
He has had two subsequent attacks of rheumatism, but with care has been 
able to live a comfortable and fairly active life. On the other hand, when f 
the aortic insufficiency is only a part of an extensive arterio-sclerosis at the 
root of the aorta, the coronary arteries are almost invariably involved, and 
the outlook in such cases is much more serious. Sudden death is not un- 
common, either from acute dilatation during some exertion, or, more fre- 
quently, from blocking of one of the branches of the coronary arteries. 
The liability of this form to be associated with angina pectoris also adds 

to its severity. Aortic stenosis is a comparatively rare lesion, most com- 
monly met with in middle-aged or elderly men, and is, as a rule, well com- 
pensated. In Broadbent's series of cases, in which autopsy showed definite 
aortic narrowing, forty years was the average age at death, and the oldest 
was but fifty-three. 

In mitral lesions the outlook on the whole is much more favorable than 
in aortic insufficiency. Mitral insufficiency, when well compensated, car- 
ries with it a better prognosis than mitral stenosis. Except aortic stenosis, 
it is the only lesion commonly met with in patients over threescore years. 
It must be borne in mind that the cases which last the longest are those in 
which the valve orifice is more or less narrowed, as well as incompetent. 
There is, in reality, no valve lesion so poorly compensated and so rapidly 
fatal as that in which the mitral segments are gradually curled and puckered 
until they form a narrow strip around a wide mitral ring — a condition 
specially seen in children. There are many cases of mitral insufficiency 
m which the defect is thoroughly balanced for thirty or even forty years, 
without distress or inconvenience. Even with great hypertrophy and the 
apex beat almost in the mid-axillary line, there may be little or no distress, 
and the compensation may be most effective. Women may pass safely 
through repeated pregnancies, though here they are liable to accidents asso- 



730 



DISEASES OF THE CIRCULATORY SYSTEM. 



ciated with the severe strain. I have had under observation for many years 
a patient who had her first attack of rheumatism at the age of fifteen, when 
she already had a well-marked mitral murmur. She first came under my 
observation, twenty-seven years ago, with signs of hypertrophy of the left 
ventricle and a loud systolic murmur. She has had no cardiac disturbance 
whatever, though she has lived a very active life, has been unusually vigor- 
ous, has borne eleven children, and has passed through three subsequent 
attacks of rheumatism. 

In mitral stenosis the prognosis is usually regarded as less favorable. 
My own experience has led me, however, to place this lesion almost on a 
level, particularly in women, with the mitral insufficiency. It is found 
very often in persons in perfect health, who have had neither palpitation 
nor signs of heart-failure, and who have lived laborious lives. The figures 
given, too, by Broadbent indicate that the date of death in mitral stenosis 
is comparatively advanced. Of 53 cases abstracted from the post-mortem 
records of St. Mary's Hospital, thirty-three was the age for males, and 
thirty-seven or thirty-eight for females. These women, too, pass through 
repeated pregnancies with safety. There are of course those too common 
accidents, the result of cerebral embolism, which are more likely to occur 
in this than in other forms. 

Hard and fast lines cannot be drawn in the question of prognosis in 
valvular disease. Every case must be judged separately, and all the cir- 
cumstances carefully balanced. There is no question which requires greater 
experience and more mature judgment, and even the most experienced are 
sometimes at fault. 

The following brief summary of the conditions which justify a favor- 
able prognosis embodies the large and varied clinical experience of Sir 
Andrew Clark: Good general health; just habits of living; no exceptional 
liability to rheumatic or catarrhal affections; origin of the valvular lesion 
independently of degeneration; existence of the valvular lesion without 
change for over three years; sound ventricles, of moderate frequency and 
general regularity of action; sound arteries, with a normal amount of blood 
and tension in the smaller vessels; free course of blood through the cer- 
vical veins; and, lastly, freedom from pulmonary, hepatic, and renal con- 
gestion. 

Treatment of Valvular Lesions.— For this purpose the valvular 
lesion may be divided into the period of progressive development, with es- 
tablishment and maintenance of hypertrophy, and the period of disturbed 
compensation. 

(n) Stage of Compensation.— Medicinal treatment at this period is not 
necessary and is often hurtful. A very common error is to administer 
cardiac drugs, such as digitalis, on the discovery of a murmur or of hyper- 
trophy. If the lesion has been found accidentally, it may be best not to 
tell the patient, but rather an intimate friend. Often it is necessar}^, how- 
ever, to be perfectly frank in order that the patient may take certain pre- 
ventive measures. He should lead a quiet, regulated, orderly life, free from 
excitement and worry, and the risk of sudden death makes it imperative 
that the patient suffering from aortic disease should be specially warned 



CHRONIC VALVULAR DISEASE. 



731 



against overexertion and hurry. An ordinary wholesome diet in moderate 
quantities should be taken, tobacco should be interdicted, and stimulants 
not allowed. Exercise should be regulated entirely by the feelings of the 
patient. So long as no cardiac distress or palpitation follows, moderate ex- 
ercise will prove very beneficial. The skin should be kept active by a daily 
bath. Hot baths should be avoided and the Turkish bath should be inter- 
dicted. In the case of full-blooded, somewhat corpulent individuals, an 
occasional saline purge should be taken. Patients with valvular lesions 
should not go into very high altitudes. The act of coition has serious risks, 
particularly in aortic insufficiency. Knowing that the causes which most 
surely and powerfully disturb the compensation are overexertion, mental 
worry, and malnutrition, the physician should give suitable instructions in 
each case. As it is always better to have the co-operation of an intelligent 
patient, he should, as a rule, be told of the condition, but in this matter 
the physician must be guided by circumstances, and there are cases in 
which reticence is the wiser policy. 

(b) Stage of Broken Compensation. — The break may be immediate and 
final, as when sudden death results from acute dilatation or from blocking 
of a branch of the coronary artery, or it may be gradual. Among the first 
indications are shortness of breath on exertion or attacks of nocturnal dysp- 
noea. These are often associated with impaired nutrition, particularly 
with anaemia, and a course of iron or change of air may suffice to relieve the 
symptoms. 

Irregularity of the action of the heart cannot always be termed an in- 
dication of failing compensation, particularly in instances of mitral disease. 
It has greater significance in aortic lesions. Serious failure of compensa- 
tion is indicated by signs of dilatation of the heart, marked cyanosis, the 
gallop rhythm, or various forms of arrhythmia, with or without the ex- 
istence of dropsy. Under these circumstances the following measures are 
to be carried out: 

(1) Rest. — Disturbed compensation may be completely restored by rest 
of the body. Both in Montreal and in Philadelphia it was a favorite dem- 
onstration in practical therapeutics to show the benign influence of com- 
plete rest and quiet on the cardiac dilatation. In many cases with oedema 
of the ankles, moderate dilatation of the heart, and irregularity of the pulse, 
the rest in bed, a few doses of the compound tincture of cardamoms, and a 
saline purge suffice, within a week or ten days, to restore the compensation. 
One patient, in Ward 11 of the Montreal General Hospital, with aortic 
insufficiency recovered from four successive attacks of failing compensation 
with these measures alone. 

(2) The relief of the embarrassed circulation. 

(a) By Venesection. — In cases of dilatation, from whatever cause, whether 
in mitral or aortic lesions or distention of the right ventricle in emphysema, 
when signs of venous engorgement are marked and when there is orthopnoea 
with cyanosis, the abstraction of from 20 to 30 ounces of blood is indi- 
cated. This is the occasion in which timely venesection may save the 
patient's life. It is a condition in which I have had most satisfactory re- 
sults from blood-letting. It is done much better early than late. I have 



732 DISEASES OF THE CIRCULATORY SYSTEM. 

on several occasions regretted its postponement, particularly in instances 
of acute dilatation and cyanosis in connection with emphysema.* 

(b) By Depletion through the Bowels. — This is particularly valuable when 
dropsy is present. Of the various purges the salines are to be preferred, 
and may be given by Matthew Hay's method. Half an hour to an hour 
before breakfast from half an ounce to an ounce and a half of Epsom salts 
may be given in a concentrated form. This usually produces from three to 
five liquid evacuations. The compound jalap powder in half-drachm doses, 
or elaterium, may be employed for the same purpose. Even when the pulse 
is very feeble these hydragogue cathartics are well borne, and they deplete 
the portal system rapidly and efficiently. 

(c) The Use of Remedies which stimulate the Heart's Action. — Of these, 
by far the most important is digitalis, which was introduced into practice 
by Withering. The indication for its use is dilatation; the contra-indica- 
tion is a perfectly balanced compensatory hypertrophy, such as we see in all 
forms of valvular disease. Broken compensation, no matter what the 
valve lesion may be, is the signal for its use. It acts upon the heart, slow- 
ing and at the same time increasing the force of the contractions. It acts 
on the peripheral arteries, raising their tension, so that a steady and equable 
flow of blood is maintained in the capillaries, which, after all, is the prime 
aim and object of the circulation. The beneficial effects are best seen in 
cases of mitral disease with small, irregular pulse and cardiac dropsy. Its 
effects are not less striking in the dilatation of the left ventricle, in the 
failing compensation of aortic insufficiency or of arterio-sclerosis. On theo- 
retical grounds it has been urged that its use is not so advantageous in 
aortic insufficiency, since it prolongs the diastole and leads to greater dis- 
tention. This need not be considered, and digitalis is just as serviceable 
in this as in any other condition associated with progressive dilatation; 
larger doses are often required. It may be given as the tincture or the in- 
fusion. In cases of cardiac dropsy, from whatever cause, 15 minims of the 
tincture or half an ounce of the infusion may be given every three hours 
for two days, after which the dose may be reduced. Some prefer the tinc- 
ture, others the infusion; it is a matter of indifference if the drug is good. 
The urine of a patient taking digitalis should be carefully estimated each 
day. As a rule, when its action is beneficial, there is within twenty-four 
hours an increase in the amount; often the flow is very great. Under its 
use the dyspnoea is relieved, the dropsy gradually disappears, the pulse be- 
comes firmer, fuller in volume, and sometimes, if it has been very inter- 
mittent, regular. 

Ill effects sometimes follow digitalis. There is no such thing as a 
cumulative action of the drug manifested by sudden symptoms. Toxic 
effects are seen in the production of nausea and vomiting. The pulse be- 
comes irregular and small, and there may be two beats of the heart to one 
of the pulse, which, as pointed out by Broadbent, is found particularly in 
cases of mitral stenosis when they are under the influence of this drug. 



* For illustrative cases from my wards see paper by H. A. Lafleur, Medical News, 
July, 1891. 



CHRONIC VALVULAR DISEASE. 



733 



The urine is reduced in amount. These symptoms subside on the with- 
drawal of the digitalis, and are rarely serious. There are patients who take 
digitalis uninterruptedly for years, and feel palpitation and distress if the 
drug is omitted. In mitral disease, even when it does good it does not al- 
ways steady the pulse. There are many cases in which the irregularity is 
not affected by the digitalis. When the compensation has been re-estab- 
lished the drug may be omitted. When there is dyspnoea on exertion and 
cardiac distress, from 5 to 10 minims three times a day may be advan- 
tageously given for prolonged periods, but the effects should be carefully 
watched. In cardiac dropsy digitalis should be used at the outset with a 
free hand. Small doses should not be given, but from the first half -ounce 
doses of the infusion every three hours, or from 15 to 20 minims of the 
tincture. Digitalin, hypodermically (gr. ^V) every three or four hours, 
may be substituted. 

Of other remedies strophanthus alone is of service. Given in doses of 
from 5 to 8 minims of the tincture, it acts like digitalis. It certainly will 
sometimes steady the intermittent heart of mitral valve disease when digi- 
talis fails to do so, but it is not to be compared with this drug when dropsy 
is present. Convallaria, citrate of caffeine, and adonis vernalis and spar- 
teine are warmly recommended as substitutes for digitalis, but their infe- 
riority is so manifest that their use is rarely indicated. 

There are two valuable adjuncts in the treatment of valvular disease — ■ 
iron and strychnia. When ana?mia is a marked feature iron should be 
given in full doses. In some instances of failing compensation this is the 
only medicine needed to restore the balance. Arsenic is occasionally an 
excellent substitute, and one or other of them should be administered in 
all instances of heart-trouble when pallor is present. Strychnia is a heart 
tonic of very great value. It may be given alone or in combination with the 
digitalis in 1 or 2 drop doses of the 1-per-cent solution. Alcoholic stimu- 
lants in moderation are occasionally useful, especially in tiding over a period 
of acute cardiac weakness. 

Treatment of Special Symptoms, (a) Dropsy. — The increased 
arterial tension and activity of the capillary circulation under the influence 
of digitalis hastens the interstitial lymph flow and favors resorption of the 
fluid. The hydragogue cathartics, by rapidly depleting the blood, promote, 
too, the absorption of the fluid from the lymph spaces and the lymph sacs. 
These two measures usually suffice to rid the patient of the dropsy. In 
some cases, however, it cannot be relieved, and then Southey's tubes may 
be used or the legs punctured. If done with care, after a thorough wash- 
ing of the parts, and if antiseptic precautions are taken, scarification is a 
very serviceable measure, and should be resorted to more frequently than it 
is. Canton flannel bandages may be applied on the (Edematous legs. 

(/;) Dyspnoea. — The patients are usually unable to lie down. A com- 
fortable bed-rest should therefore be provided — if possible, one with lateral 
projections, so that in sleeping the head can be supported as it falls over. 
The shortness of breath is associated with dilatation, chronic bronchitis, 
or hydrothorax. The chest should be carefully examined in all these cases, 
as hydrothorax of one side or of both is a common cause of shortness of 
breath. There are cases of mitral regurgitation with recurring hydrothorax 



734 



DISEASES OF THE CIRCULATORY SYSTEM. 



usually on the right side, which is relieved, week by week or month by 
month, by tapping. For the nocturnal dyspnoea, particularly when com- 
bined with restlessness, morphia is invaluable and may be given without 
hesitation. The value of the calming influence of opium in all conditions 
of cardiac insufficiency is not enough recognized. There are instances of 
cardiac dyspnoea unassociated with dropsy, particularly in mitral valve dis- 
ease, in which nitroglycerin is of great service, if given in the 1-per-cent 
solution in increasing doses. It is especially serviceable in the cases in 
which the pulse tension is high. 

(c) Palpitation and Cardiac Distress. — In instances of great hypertrophy 
and in the throbbing which is so distressing in some cases of aortic in- 
sufficiency, aconite is of service in doses of from 1 to 3 minims every two 
or three hours. An ice-bag over the heart or Letter's coil is also of service 
in allaying the rapid action and the throbbing. For the pains, which are 
often so marked in aortic lesions, iodide of potassium in 10-grain doses, 
three times a day, or the nitroglycerin may be tried. Small blisters are 
sometimes advantageous. It must be remembered that an important cause 
of palpitation and cardiac distress is flatulent distention of the stomach 
or colon, against which suitable measures must be directed. 

(d) Gastric Symptoms. — The cases of cardiac insufficiency which do 
badly and fall to respond to digitalis are most often those in which nausea 
and vomiting are prominent features. The liver is often greatly enlarged 
in these cases; there is more or less stasis in the hepatic vessels, and but 
little can be expected of drugs until the venous engorgement is relieved. 
If the vomiting persists, it is best to stop the food and give small bits of 
ice, small quantities of milk and lime water, and effervescing drinks, such 
as Apollinaris water and champagne. Creasote, hydrocyanic acid, and the 
oxalate of cerium are sometimes useful; but, as a rule, the condition is ob- 
stinate and always serious. 

(e) Cough and Hwmoptysis. — The former is almost a necessary concomi- 
tant of cardiac insufficiency, owing to engorgement of the pulmonary ves- 
sels and more or less bronchitis. It is allayed by measures directed rather 
to the heart than to the lungs. Haemoptysis in chronic valvular disease 
is sometimes a salutary symptom. An army surgeon, who was invalided 
during the late civil war on account of haemoptysis, supposed to be due 
to tuberculosis, had for many years, in association with mitral insuffi- 
ciency and enlarged heart, many attacks of haemoptysis. He assured me 
that his condition was invariably better after the attack. It is rarely fatal, 
except in some cases of acute dilatation, and seldom calls for special treat- 
ment. 

(/) Sleeplessness. — One of the most distressing features of valvular le- 
sions, even in the stage of compensation, is disturbed sleep. Patients may 
wake suddenly with throbbing of the heart, often in an attack of night- 
mare. Subsequently, when the compensation has failed, it is also a worry- 
ing symptom. The sleep is broken, restless, and frequently disturbed by 
frightful dreams. Sometimes a dose of the spirits of chloroform or of ether, 
with half a drachm of spirits of camphor, given in a little hot whisky, will 
give a quiet night. The compound spirits of ether, Hoffmann's anodyne, 



HYPERTKOPHY AND DILATATION. 



735 



thougli very unpleasant to take, is frequently a great boon in the inter- 
mediate period when compensation has partially failed and the patients 
suffer from restless and sleepless nights. Paraldehyde and amylene hydrate 
are sometimes serviceable. Urethan, sulphonal, and chloralamide are rarely 
efficacious, and it is best, after a few trials, particularly if the paraldehyde 
does not answer, to resort to morphia. It may be given in combination with 
atropine. 

(g) Renal Symptoms. — With ruptured compensation and lowering of 
the tension in the aorta, the urinary secretion is greatly diminished, and 
the amount may sink to 5 or 6 ounces in the day. Digitalis, and strophan- 
thus when efficient, usually increase the flow. A brisk purge may be fol- 
lowed by augmented secretion. The combination in pill form of digitalis, 
squill, and the black oxide of mercury, will sometimes prove effective when 
the infusion or tincture of digitalis alone has failed. Calomel acts well in 
some cases, given in 3-grain doses every six hours for three or four days. 

The diet in chronic valve-diseases is often very difficult to regulate. 
With the dilatation and venous engorgement come nausea and often a great 
distaste for food. The amount of liquid should be restricted, and milk, 
beef-juice, or egg albumen given every three hours. When the serious 
symptoms have passed, eggs, scraped meat, fish, and fowl may be allowed. 
Starchy foods, and all articles likely to cause flatulency, should be for- 
bidden. Stimulants are usually necessary, either whisky or brandy. 



III. HYPERTROPHY AND DILATATION. 

Hypertrophy is an enlargement of the heart due to an increased thick- 
ness, total or partial, in the muscular walls. Dilatation is an increase in 
size of one or more of the chambers, Avith or without thickening of the walls. 
The conditions usually coexist, and could be more correctly described to- 
gether under the term enlargement of the heart. Simple hypertrophy, in 
which the cavities remain of a normal size and the walls are increased, 
occurs, but simple dilatation, in which the cavities are increased and the 
walls remain of a normal diameter, probably does not, as it is always asso- 
ciated with thinning or with thickening of the coats. Commonly we have 
the forms of simple hypertrophy, hypertrophy with dilatation, and dilatation 
with thinning of the coats. 

Hypertrophy of the Heart. 

There are two forms — the simple hypertrophy, in which the cavity or 
cavities are of normal size; and hypertrophy with dilatation (eccentric 
hypertrophy), in which the cavities are enlarged and the walls increased in 
thickness. The condition formerly spoken of as concentric hypertrophy, 
in which there is diminution in the size of the cavity with thickening of 
the walls, is, as a rule, a post-mortem change. 

The enlargement may affect the entire organ, one side, or only one 
chamber. Naturally, as the left ventricle does the chief work in forcing 
46 



736 



DISEASES OF THE CIRCULATORY SYSTEM. 



the blood through the systemic arteries, the change is most frequently 
found in it. 

Etiology. — Hypertrophy of the heart follows the law governing mus- 
cles, that within certain limits, if the nutrition is kept up, increased work 
is followed by increased size — i. e., hypertrophy. Hypertrophy of the left 
ventricle alone, or with general enlargement of the heart, is brought 
about by — 

Conditions affecting the heart itself: (1) Disease of the aortic valve; 
(2) mitral insufficiency; (3) pericardial adhesions; (4) sclerotic myocarditis; 
(5) disturbed innervation, with overaction, as in exophthalmic goitre, in 
long-continued nervous palpitation, and as a result of the action of certain 
articles, such as tea, alcohol, and tobacco. In all of these conditions the 
Avork of the heart is increased. In the case of the valve lesions the increase 
is due to the increased intraventricular pressure; in the case of the adherent 
pericardium and myocarditis, to direct interference with the symmetrical 
and orderly contraction of the chambers. 

Conditions acting upon the blood-vessels: (1) General arterio-sclerosis, 
with or without renal disease; (2) all states of increased arterial tension 
induced by the contraction of the smaller arteries under the influence of 
certain toxic substances, which, as Bright suggested, " by affecting the 
minute capillary circulation, render greater action necessary to send the 
blood through the distant subdivisions of the vascular system (3) pro- 
longed muscular exertion, which enormously increases the blood-pressure 
in the arteries; (4) narrowing of the aorta, as in the congenital stenosis. 

Hypertrophy of the right ventricle is met with under the following 
conditions — 

(1) Lesions of the mitral valve, either incompetence or stenosis, which 
act by increasing the resistance in the pulmonary vessels. (2) Pulmonary 
lesions, obliteration of any number of blood-vessels within the lungs, such 
as occurs in emphysema or cirrhosis, is followed by hypertrophy of the 
right ventricle. (3) Valvular lesions on the right side occasionally cause 
hypertrophy in the adult, not infrequently in the foetus. (4) Chronic 
valvular disease of the left heart and pericardial adhesions are sooner or 
later associated with hypertrophy of the right ventricle. 

In the auricles simple hypertrophy is never seen; there is always dilata- 
tion with hypertrophy. In the left auricle the condition develops in lesions 
at the mitral orifice, particularly stenosis. The right auricle hypertrophies 
when there is greatly increased blood-pressure in the lesser circulation, 
whether due to mitral stenosis or pulmonary lesions. Narrowing of the 
tricuspid orifice is a less frequent cause. 

Morbid Anatomy. — The heart of an average-sized man weighs about 
9 ounces (280 grammes); that of a woman, about 8 ounces (250 grammes). 
In case of general hypertrophy the heart may weigh from 16 to 20 ounces. 
"Weights above 25 ounces are rare. So far as I know, the heaviest heart 
on record is one of 53 ounces, described by Beverly Robinson. Dulles 
has reported one weighing 48 ounces. The measurement of the thickness 
of the walls is, next to weighing, the best means of determining the hyper- 
trophy. In extreme dilatation the walls, though actually thickened, may 



HYPERTROPHY AND DILATATION. 



737 



look thin. When rigor mortis is present, the cavity may be small and the 
walls may appear greatly thickened. The measurements should not be 
made until the heart has been soaked in water and thoroughly relaxed. In 
the left ventricle a thickness of ten lines^ or from 20 to 25 mm., indicates 
hypertrophy. The right ventricle is thinner than the left, and has an 
average diameter of from 4 to 7 mm. In hypertrophy it may measure from 
13 to 20 mm. The left auricle has a normal thickness of about 3 mm., 
which may be doubled in hypertrophy. The wall of the right auricle is 
thinner than that of the left, rarely exceeding 2 mm. in diameter. The 
appendices of the auricles often present marked increase in thickness and 
the musculi pectinati are greatly developed. 

The shape of the heart is altered in hypertrophy; with great enlarge- 
ment of the ventricles, the apex is broadened, and the conical shape is lost. 
In the enormous enlargement of aortic insufficiency this rotundity of the 
apex is very marked. When the right, ventricle is chiefly affected it occu- 
pies the largest share of the apex. In mitral stenosis the contrast is very 
striking between the large, broad right ventricle, reaching to the apex, and 
the small left chamber. 

The hypertrophied muscle has a deep red color, is firm, and is cut with 
increasing resistance. The right ventricle, as Eokitansky noted, may have 
a peculiar hard, leathery consistence. In simple hypertrophy of the left 
ventricle the papillary muscles and the columnar carneae may be enlarged, 
but the former are often much flattened in dilated hypertrophy. The 
muscular trabecular are more developed, as a rule, in the right ventricle 
than in the left. 

The increase in size of the heart is probably due to a definite numerical 
increase, resulting from development of new fibres. 

Symptoms. — Hypertrophy is a conservative process, secondary to 
some valvular or arterial lesion, and is not necessarily accompanied by 
symptoms. So admirable is the adjusting power of the heart that, for 
example, an advancing stenosis of aortic or mitral orifice may for years be 
perfectly equalized by a progressive hypertrophy, and the subject of the 
affection be happily unconscious of the existence of heart trouble. Hyper- 
trophy is in almost all cases an unmixed good; the symptoms which arise 
are usually to be attributed to its failure, or, as we say, to disturbance of 
compensation. 

Among the most common symptoms are unpleasant feelings about the 
heart — a sense of fulness and discomfort, rarely amounting to pain. This 
may be very noticeable when the patient is recumbent on the left side. 
Actual pain is rare, except in the irritable heart from tobacco or in neur- 
asthenics. Palpitation may not occur, nor do patients always have sensa- 
tions from the violent shocks of a greatly hypertrophied organ. There 
are instances in which very uneasy feelings arise from a moderately exag- 
gerated pulsation. The general condition has much to do with this. In 
health we are not conscious of the heart's pulsations, but one of the first 
indications of exhaustion from excesses or overstudy is the consciousness 
of the heart's action, not necessarily with palpitation. Headaches, flush- 
ings of the face, noises in the ears, and flashes of light may be present. 



738 



DISEASES OF THE CIRCULATORY SYSTEM. 



Certain untoward effects of long-continued hypertrophy of the left 
ventricle must be mentioned, chief among which is the production of 
arterio-sclerosis. Particularly is this the case when the hypertrophy results 
from increased peripheral resistance. The heightened blood-pressure (ex- 
pressed by the word strain) in the arteries gradually induces an endarteritis 
and a stiff, inelastic state of those vessels most exposed to it — viz., the 
aorta and its primary divisions. In overcoming the peripheral obstruction 
the hypertrophy " ruins the arteries as a sequential result " (Fothergill). 
Prolonged muscular exertion also acts injuriously in this way. 

Another danger is rupture of the blood-vessels, particularly those of the 
brain. In general arterial degeneration associated with contracted kidneys 
and hypertrophied left heart apoplexy is common. Indeed, in the majority 
of cases of cerebral haemorrhage there is sclerosis of the smaller vessels, 
often with the development of miliary aneurisms, and the rupture may be 
caused by the forcible action of the heart. 

Physical Signs. — Inspection may show bulging of the prsecordia, pro- 
ducing in children marked asymmetry of the chest. It may occur with- 
out pericardial adhesions, which Schroetter thinks are invariably associated 
with this condition. The intercostal spaces are widened, and the area of 
visible impulse is much increased. On palpation the impulse is forcible 
and heaving, and with each systole the hand or the ear applied over the 
heart may be visibly raised. A slow, heaving impulse is one of the best 
signs of simple hypertrophy. AYith large dilated hypertrophy the forcible 
impulse is often more sudden and abrupt. A second, weaker impulse can 
sometimes be felt, due perhaps to a rebound from the aortic valves (Gowers). 
The beat may be felt in the sixth, seventh, or eighth interspace from 1 
to 3 inches outside the nipple. This downward dislocation of the apex 
is an important sign in hypertrophy of the left ventricle. In moderate 
grades, such as are seen in chronic Bright's disease, the impulse may be in 
the sixth interspace in the nipple line, or a little outside of it. 

Percussion reveals increased dulness, which in the parasternal line may 
begin at the third rib or in the second interspace, and transversely may 
extend from half an inch to 2 inches beyond the nipple line and an 
equal distance beyond the middle line of the sternum. The dull area is 
more ovoid than in health. When carefully delimited the colossal hyper- 
trophy of aortic valve disease may give an area of dulness from 7 to 8 
inches in transverse extent. In moderate grades a transverse dulness of 4 
inches is not uncommon. 

On auscultation the sounds, when the valves are healthy, may present 
no special changes, but the first sound is often prolonged and dull. When 
there is dilatation as well, it may be very clear and sharp. Keduplication 
is common in the hypertrophy of renal disease. A peculiar clink — the 
tintement metallique of Bouillaud — may be heard just to the right of the 
apex beat. The second sound is clear and loud, sometimes ringing in char- 
acter or reduplicated. With valvular lesions, the sounds, of course, are 
much altered, and are replaced or accompanied by murmurs. 

In simple hypertrophy not dependent on valvular lesions, the pulse 
is usually regular, full, strong, and of high tension. It may be increased 



HYPERTROPHY AND DILATATION. 



739 



in rapidity, but is often normal. In eccentric hypertrophy the pulse is full, 
but softer, and usually more rapid. One of the earliest signs of failure and 
dilatation is irregularity and intermittence of the pulse. 

Hypertrophy of the right ventricle in the adult very rarely follows valvu- 
lar disease on the right side, but results from increased resistance in the 
pulmonary circulation, as in cirrhosis of the lung and emphysema, or in 
stenosis of the mitral orifice. With perfect compensation, which fully 
maintains the equilibrium of the circulation, there are no symptoms. Extra 
exertion, as the ascent of stairs or running, may cause shortness of breath, 
but in many ways hypertrophy of the right ventricle is the most enduring 
and salutary form in the whole cycle of cardiac affections. For long 
periods of years the effects of mitral stenosis may be counterbalanced, and 
only sudden death by accident or an acute disease reveal the existence of 
an unsuspected lesion. In the hypertrophy secondary to emphysema or 
cirrhosis of the lungs, there may be sensations of distress in the cardiac 
region, with cough and shortness of breath; but as long as the dilatation 
is moderate the symptoms are not marked. With great dilatation and 
tricuspid leakage come venous engorgement, oedema, and pulmonary trou- 
bles. The increased pressure in the lesser circulation induces sclerosis of 
the pulmonary arteries and the constant engorgement of the capillaries 
leads ultimately to a deposition of pigment and increase in the fibrous 
elements in the lung — the brown induration. Extreme pulmonary con- 
gestion and apoplexy are more often associated with dilatation. Haemop- 
tysis may result from rupture of vessels during sudden exertion. 

Physical Signs. — Bulging of the lower part of the sternum and left 
cartilages occurs. The apex beat is forced to the left, but is not so often 
displaced downward. The most marked impulse may be in the angle be- 
tween the ensiform cartilage and the seventh rib or beneath the cartilages 
of the sixth and seventh ribs. The pulsation is rather diffuse, not punc- 
tate, particularly if there is much dilatation. In thin-walled chests there 
may be pulsation in the third and fourth right interspaces. The cardiac 
dulness is increased transversely and toward the right; it may extend an 
inch or more beyond the border of the sternum. On auscultation the first 
sound at the lower part of the sternum is louder and fuller than normal, 
but the differences are not very marked unless there is much dilatation, 
when the sound is clearer and sharper. Accentuation and reduplication 
of the second sound are heard in the pulmonary artery on account of the 
increased tension. The pulse at the wrist is usually small. Pulsation 
occurs in the jugulars when there is tricuspid incompetence. 

Hypertrophy of the auricles always occurs with dilatation. It is more 
common in the left chamber, which hypertrophies in mitral stenosis and 
incompetency, and naturally assists in restoring the balance of the circu- 
lation. There are no distinctive physical signs, and we usually can infer 
its presence only by the existence of mitral stenosis and a presystolic mur- 
mur. Increased dulness may be determined to the left of the sternum, and 
there may be a presystolic wave in the second left interspace. 

Hypertrophy and dilatation of the right auricle are met with (associ- 
ated with a similar condition in the right ventricle and incompetency of 



740 



DISEASES OF THE CIRCULATORY SYSTEM. 



the tricuspid) in emphysema, cirrhosis of the lung, chronic bronchitis, and 
mitral disease. In comparison with the left auricle the greater develop- 
ment and hypertrophy of the appendix and its musculi pectinati is very 
striking. The latter may be distributed over the anterior wall of the sinus 
to a greater extent than in health. There are increased dulness in the 
third and fourth interspaces, pulsation sometimes presystolic in rhythm, 
signs of venous engorgement, jugular pulsation, and other evidences of 
dilatation of the right heart. 

Diagnosis. — Among conditions to be distinguished are: 

(1) Neurotic palpitation, from whatever cause, even when very forcible, 
has not the heaving impulse of genuine hypertrophy. Enlargement of the 
organ may, however, follow prolonged overaction, as in the smoker's heart, 
the irritable heart of neurasthenics, and in exophthalmic goitre, but it is 
usually slight. 

(2) The increased area of dulness may be due to a variety of causes, 
some of which may closely simulate hypertrophy, such as pericardial effu- 
sion, aneurism, mediastinal growths, or displacement of the heart from 
pressure, or the existence of malformation of the chest. With the exer- 
cise of ordinary care, however, the diagnosis can usually be made. There 
are two opposite conditions which frequently give trouble. With the left 
lung contracted from pleurisy, phthisis, or cirrhosis, a large surface of the 
heart is exposed; the pulsation may be extensive and forcible, and may at 
first sight suggest hypertrophy. In this condition there is dislocation 
upward and to the left. The existence of pulmonary or pleuritic disease 
and the fixation of the lung on deep inspiration will suffice to prevent 
mistakes. A less extensive exposure of the heart may occur without any 
disease in very narrow-chested persons with ill-developed lungs; here, 
though the area of dulness may be much increased, the normal position 
of the apex, the absence of forcible, heaving impulse, and of any obvious 
cause of hypertrophy will afford satisfactory criteria for a diagnosis. The 
reverse condition exists in some cases in which emphysema masks moderate 
cardiac hypertrophy. The area of dulness may be normal, or even dimin- 
ished, and the pulse and character of the sounds will help in the diagnosis; 
but a decision is sometimes difficult. 

Prognosis. — The course of any case of cardiac hypertrophy may be 
divided into three stages: 

(a) The period of development, which varies with the nature of the 
primary lesion. For example, in rupture of an aortic valve, during a sud- 
den exertion, it may require months before the hypertrophy becomes fully 
developed; or, indeed, it may never do so, and death may follow from an 
uncompensated dilatation. On the other hand, in sclerotic affections of the 
valves, with stenosis or incompetency, the hypertrophy develops step by 
step with the lesion, and may continue to counterbalance the progressive 
and increasing impairment of the valve. 

(7;) The period of full compensation — the latent stage — during which 
the heart's vigor meets the requirements of the circulation. This period 
may last an indefinite time, and a patient may never be made aware by 
any symptoms that he has a valvular lesion. 



HYPERTROPHY AND DILATATION. 



(c) The period of broken compensation, which may come on suddenly 
during very severe exertion. Death may result from acute dilatation; but 
more commonly it takes place slowly and results from degeneration and 
weakening of the heart-muscle. 

The breaking or rupture of cardiac compensation may be induced by 
many causes, among which the most important are: (1) Failure of the 
general nutrition. In many instances of heart-disease, exposure,^ poor food, 
and alcohol combine to bring about disturbance of a well-balanced heart 
lesion. Acute illnesses, particularly the fevers, may induce general debility 
and with it weakening of the heart-muscle. (2) Disturbance of the local 
nutrition of the heart, owing to gradual sclerosis of the coronary arteries, 
is a common cause. (3) Very severe muscular exertion, which may disturb 
a compensation, perfect for years, and induce death in a few days (Traube). 
(4) Mental emotions. Severe grief or fright may bring on failure of com- 
pensation. 

The prognosis is largely, as already stated, a matter of maintained com- 
pensation. Once established, the hypertrophy rarely, if ever, disappears, 
inasmuch as the cause usually persists. Occasionally, perhaps, the hyper- 
trophy associated with neurotic palpitation from tobacco, or other causes, 
or the hypertrophy following muscular overexertion, may disappear. 

Dilatation of the Heart. 

Two varieties are recognized, dilatation with thickening and dilatation 
with thinning. The former is the more common, and corresponds to the 
dilated or eccentric hypertrophy. 

Etiology. — Two important causes combine to produce dilatation — 
increased pressure within the cavities and impaired resistance, due to weak- 
ening of the muscular wall — which may act singly, but are often combined. 
A weakened wall may yield to a normal distending force, or a normal wall 
may yield under a heightened blood-pressure. 

(1) Heightened endocardiac pressure results either from an increased 
quantity of blood to be moved or an obstacle to be overcome, and is the 
more frequent cause. It does not necessarily bring about dilatation; simple 
hypertrophy may follow, as in the early period of aortic stenosis, and in the 
hypertrophy of the left ventricle in 'Bright^ s disease. 

A majority of the important causes of increased endocardiac pressure 
have already been discussed under hypertrophy. One or two may be con- 
sidered more in detail. 

The size of the cardiac chambers varies in health. With slow action 
of the heart the dilatation is complete and fuller than it is with rapid 
action. Physiologically, the limits of dilatation are reached when the 
chamber does not empty itself during the systole. This may occur as an 
acute, transient condition in severe exertion — during, for example, the 
ascent of a mountain. There may be great dilatation of the right heart, 
as shown by the increased epigastric pulsation, and even increase in the 
cardiac dulness. The safety-valve action of the tricuspid valves may here 
come into play, relieving the lungs by permitting regurgitation into the 



742 



DISEASES OF THE CIRCULATORY SYSTEM. 



auricle. With rest the condition is removed, but if it has been extreme, 
the heart may suffer a strain from which it may recover slowly, or, indeed, 
the individual may never be able again to undertake severe exertion. In 
the process of training, the getting wind, as it is called, is largely a gradual 
increase in the capability of the heart, particularly of the right chambers. 
A degree of exertion can be safely maintained in full training which would 
be quite impossible under other circumstances, because, by a gradual process 
of what we may call physical education, the heart has strengthened its 
reserve force — widened enormously its limits of physiological work. En- 
durance in prolonged contests is measured by the capabilities of the heart, 
and its essence consists in being able to meet the continuous tendency to 
overstep the limits of dilatation. 

We have no positive knowledge of the nature of the changes in the 
heart which occur in this process, but it must be in the direction of in- 
creased muscular and nervous energy. The large heart of athletes may be 
due to the prolonged use of their muscles, but no man becomes a great 
runner or oarsman who has not naturally a capable if not a large heart. 
Master McGrath, the celebrated greyhound, and Eclipse, the race-horse, 
both famous for endurance rather than speed, had very large hearts. 

Excessive dilatation during severe muscular effort results in heart- 
strain. A man, perhaps in poor condition, calls upon his heart for extra 
work during the ascent of a high mountain, and is at once seized with 
pain about the heart and a sense of distress in the epigastrium. He 
breathes rapidly for some time, is " puffed," as we say, but the symptoms 
pass off after a night's quiet. An attempt to repeat the exercise is followed 
by another attack, or, indeed, an attack of cardiac dyspnoea may come on 
while he is at rest. For months such a man may be unfitted for severe exer- 
tion, or he may be permanently incapacitated. In some way he has over- 
strained his heart and become " broken-winded." Exactly what has taken 
place in these hearts we cannot say, but their reserve force is lost, and with 
it the power of meeting the demands exacted in maintaining the circula- 
tion during severe exertion. The " heart-shock "■ of Latham includes cases 
of this nature — sudden cardiac breakdown during exertion, not due to rup- 
ture of a valve. It seems probable that sudden death in men during long- 
continued efforts, as in a race, is sometimes due to overdistention and paraly- 
sis of the heart. 

Examples of dilatation occur in all forms of valve lesions. In -aortic 
incompetency blood enters the left ventricle during diastole from the un- 
guarded aorta and from the left auricle, and the quantity of blood at the 
termination of diastole subjects the walls to an extreme degree of pressure, 
under which they inevitably yield. In time they augment in thickness> 
and present the typical eccentric hypertrophy of this condition. 

In mitral insufficiency blood which should have been driven into the 
aorta is forced into and dilates the auricle from which it came, and then 
in the diastole of the ventricle a large amount is returned from the auri- 
cle, and with increased force. In mitral stenosis the left auricle is the 
seat of greatly increased tension during diastole, and dilates as well as 
hypertrophies; the distention, too, may be enormous. Dilatation of the 



HYPERTROPHY AND DILATATION. 



743 



right ventricle is produced by a number of conditions, which were con- 
sidered under hypertrophy. All circumstances, such as mitral stenosis, 
emphysema, etc., which permanently increase the tension of the blood in 
the pulmonary vessels, cause its dilatation. 

(2) Impaired nutrition of the heart-walls may lead to a diminution of 
the resisting power so that dilatation readily occurs. 

The loss of tone due to parenchymatous degeneration or myocarditis 
in fevers may lead to a fatal condition of acute dilatation. It is a recog- 
nized cause ol death in scarlatinal dropsy (Goodhart), and may occur in 
rheumatic fever, typhus, typhoid, erysipelas, etc. The changes in the 
heart-muscle which accompany acute endocarditis or pericarditis may lead 
to dilatation, especially in the latter disease. In anaemia, leukaemia, and 
chlorosis the dilatation may be considerable. In sclerosis of the walls, the 
yielding is always where this process is most advanced, as at the left apex. 
Under any of these circumstances the walls may yield with normal blood- 
pressure. 

Pericardial adhesions are a cause of dilatation, and we generally find 
in cases with extensive and firm union considerable hypertrophy and dila- 
tation. There is usually here some impairment as well of the superficial 
layers of muscle. 

Morbid Anatomy. — The condition usually exists with hypertrophy 
in two or more chambers. It is more common on the right than on the 
left side. The most extreme dilatation is in cases of aortic incompetency, 
in which all the cavities may be enormously distended. In mitral stenosis 
the left auricle is often trebled in capacity, and the right chambers also are 
very capacious. The auricles may contain from 18 to 20 ounces of blood. 
In chronic lesions of the lungs the right chambers are chiefly involved. 
In great distention of one ventricle the septum may bulge toward the other 
side. The auriculo-ventricular rings are often dilated,, and there may be 
an increase in the circumference of or even 2 inches. Thus, the tricus- 
pid orifice, the circumference of which is about inches, may freely admit 
a graduated heart-cone of above 6 inches; and the mitral orifice, which 
normally is about 3-J inches, may admit the cone to inches or even 
more. Great dilatation is always accompanied by relative incompetency 
of the valves, so that free regurgitation into the auricles is permitted. 
The orifices of the vena? cavae and of the pulmonary veins may be greatly 
dilated. 

The endocardium is often opaque, particularly that of the auricles. 
The muscle substance varies according to the presence or absence of de- 
generations. The microscope may show marked fatty or parenchymatous 
change, but in some instances no special alteration may be noticeable. 
There is much truth in Niemeyer's assertion "that it is not possible by 
means of the microscope to recognize all the alterations of the muscular 
fibrillae which diminish the functional power of the heart/' Of the changes 
in the ganglia of the heart we know very little. As centres of control 
they probably have more to do with cardiac atony and breakdown than we 
generally admit. Degeneration of them has been noted by Putjakin, Ott, 
and others. 



744 



DISEASES OF THE CIRCULATORY SYSTEM. 



Symptoms and Physical Signs. — Dilatation causes weakness of 
the cardiac walls, diminishes the vigor of their contractions, and is there- 
fore the reverse of hypertrophy. So long as compensation is maintained 
the enlargement of a cavity may be considerable. The limit is reached 
when the hypertrophied walls in the systole can no longer expel all the 
contents, part of which remain, so that at each diastole the chamber is 
abnormally full. Thus, in aortic incompetency blood enters the left ven- 
tricle from the aorta as well as the auricle; dilatation ensues, and also 
hypertrophy as a direct effect of the increased pressure and increased 
amount of blood to be moved. But if from any cause the hypertrophy 
weakens and the ventricle during systole fails to empty itself completely, 
a still larger amount is in it at the end of each diastole, and the dilatation 
becomes greater. The amount remaining after systole prevents the blood 
from entering freely from the auricle. Incompetency of the auriculo- 
ventricular valves follows, with dilatation of the auricle and impeded 
blood-flow in the pulmonary veins. Dilatation and hypertrophy of the 
right heart may compensate for a time, but when this fails the venous 
system becomes engorged and dropsy may result. The consideration of 
the symptoms of chronic valvular lesions is largely that of dilatation and 
its effects. Acute dilatation, such as we see in fevers or in sudden failure 
of a hypertrophied heart, is accompanied by three chief symptoms — weak, 
usually rapid, impulse, dyspnoea, and signs of obstructed venous circula- 
tion. Cardiac pain may be present, but is often absent. 

The 'physical signs of dilatation are those of a weak and enlarged 
organ. The impulse is diffuse, often undulatory, and is felt over a wide 
area, and an apex beat or a point of maximum intensity may not be found. 
When it does exist, it may be visible and yet cannot be felt — a valuable 
observation made by Walshe. An extensive area of impulse with a quick, 
weak maximum apex beat may be present. When the right heart is chiefly 
dilated the left may be pushed over so as to occupy a much less extensive 
area in front of the heart, and the true apex beat cannot be felt; but the 
chief impulse is just below, or to the right of, the xiphoid cartilage, and 
there is a wavy pulsation in the fourth, fifth, and sixth interspaces to the 
left of the sternum. In extreme dilatation of the right auricle a pulsation 
may sometimes be seen in the third right interspace close to the sternum, 
and with free tricuspid regurgitation this may be systolic in character. 
The pulsation frequently seen in the second left interspace is never due to 
a dilated left auricle as was formerly thought. It is always the throbbing 
conus arteriosus, and the rhythm can be determined to be systolic in time. 
Post mortem, it is rare in the most extreme distention to see the auricular 
appendix so far forward as to warrant the belief that it could beat against 
the second interspace. The area of dulness is increased, but an emphysema- 
tous lung or the fully distended organ in a state of brown induration may 
cover over the heart and greatly limit the extent. The directions of in- 
crease were considered in connection with hypertrophy. 

The first sound is shorter, sharper, more valvular in character, and 
more like the second. As the dilatation becomes excessive it gets weaker. 
Reduplication is not common, but occasionally differences may be heard 



HYPERTROPHY AND DILATATION. 



745 



in the first sound over the right and left hearts. The sounds are frequently 
obscured by murmurs, which are produced by incompetency of the valves 
due to the great dilatation, or are associated with the chronic valve dis- 
ease on which the condition depends. The aortic second sound is replaced 
by a murmur in aortic regurgitation. The pulmonary sound is accentuated 
in mitral regurgitation and pulmonary congestion, but with extreme dilata- 
tion it may be much weakened. The heart's action is irregular and inter- 
mittent, and the pulse is small, weak, and quick. 

On auscultation both the sounds may be free from murmur. There 
is the condition known as embryocardia or fcetal heart-rhythm, in which 
the first and second sounds are very alike, and the long pause is shortened. 
In other instances there is the typical and, characteristic gallop rhythm, 
rarely found apart from conditions of dilatation. With the various valvu- 
lar lesions the corresponding murmurs may be heard. Murmurs, however, 
which have been present may disappear, as in the case of mitral stenosis. 
In other instances a loud systolic murmur may be heard at the apex, and 
when the case first comes under observation it may be impossible to say 
whether this is due to organic mitral lesion. The murmur may be con- 
fined to the apex region, or propagated well to the back. It is extremely 
common in the dilatation which follows the hypertrophy of the left ventri- 
cle in arterio-sclerosis. Under treatment, with the gradual disappearance 
of the dilatation, a murmur of this kind, even though most intense, may 
completely disappear, showing that it has been due to a relative insufficiency, 
not to a valvular lesion. All varieties of arrhythmia may occur in dilata- 
tion of the heart. The pulse, as a rule, is small, weak, quick, and often 
irregular. 

Dilation and Hypertrophy due to Overexertion and Alcohol. — There 
is a group of cases of dilatation and hypertrophy dependent upon pro- 
longed overexertion, which rarely comes under observation until compen- 
sation has failed, and which then may be very difficult to distinguish from 
the similar conditions produced by valvular disease. The patients are 
able-bodied men at the middle period of life, and complain first of pal- 
pitation or irregularity of the action of the heart and shortness of breath; 
subsequently the usual symptoms of cardiac insufficiency develop. On in- 
quiring into the history of these patients none of the usual etiological 
factors causing valve-disease are present, but they have always been en- 
gaged in laborious occupations and have usually been in the habit of taking 
stimulants freely. This is the affection Avhich has been specially studied 
by McLean, Clifford Allbutt, Seitz, and others, and in its earlier condition 
by Da Costa, in what he termed the irritable heart. It is met with very 
frequently in soldiers. These cases may return to hospital three or four 
times with cardiac insufficiency, sometimes with slight anasarca, haemop- 
tysis, and signs of pulmonary engorgement. The condition is by no means 
infrequent. Bollinger has called attention to the common occurrence of 
dilatation and hypertrophy in beer-drinkers, particularly in the workers 
in the German breweries, who drink 20 or more litres in the day. Striim- 
pell, at his Erlangen clinic, told me that this condition was very common 
in the draymen and workers in the breweries of that town, very few of 



746 



DISEASES OF THE CIRCULATORY SYSTEM. 



whom pass the forty-fifth year without indications of hypertrophy and 
dilatation of the heart. On post-mortem examination the valves may be 
quite healthy, the aorta smooth, and extensive arterio-sclerosis or renal dis- 
ease absent. The heart weighs from 18 to 25 ounces; the chambers are 
dilated. The condition has been met with also in animals, and Houghton 
states that the heart of the celebrated greyhound Master McGrath weighed 
9.57 ounces, just threefold in excess of the normal proportion of heart- 
weight to body-weight. 

Idiopathic Dilatation. — And, lastly, there are other cases in which dila- 
tation of the heart occurs without discoverable cause. In some instances 
there has been a history of sudden exercise or of mental emotion, but in 
other cases the condition seems to have come on spontaneously. In some 
it is acute and the patient has dyspnoea, slight cyanosis, cough, and great 
cardiac distress. Death may occur in a few days, or dropsy may supervene 
and the case may become chronic. Delafield has reported an interesting 
series of cases of this group. 

Treatment. — The treatment of hypertrophy and dilatation has al- 
ready been considered under the section on valvular lesions. I would 
only here emphasize the fact that with signs of dilatation, as indicated by 
gallop rhythm, urgent dyspnoea, and slight lividity, venesection is in many 
cases the only means by which the life of the patient may be saved, and 
from 25 to 30 ounces of blood should be abstracted without delay. Subse- 
quently stimulants, such as ammonia and digitalis, may be administered, 
but they are accessories only to the bleeding in the critical condition of 
acute dilatation, which is so frequently met with in cardiac lesions. 



IV. AFFECTIONS OF THE MYOCARDIUM. 

1. Lesions due to Disease of the Coronary Arteries. — A knowledge of the 
changes produced in the myocardium by disease of the coronary vessels 
gives a key to the understanding of many problems in cardiac pathology. 
The terminal branches of the coronary vessels are end-arteries; that is, the 
communication between neighboring branches is through capillaries only. 
F. H. Pratt * has lately shown that the vessels of Thebesius, which open 
from the ventricles and auricles into a system of fine branches and thus 
communicate with the cardiac capillaries and coronary veins, may be ca- 
pable of feeding the myocardium sufficiently to keep it alive even when the 
coronary arteries are occluded. The blocking of one of these vessels by a 
thrombus or an embolus leads usually to a condition which is known as — 

(a) Anaemic necrosis, or white infarct. When this does not occur the 
reason may be sought in (1) the existence of abnormal anastomoses, which 
by their presence take the coronary system out of the group of end-arteries; 
or (2) the vicarious flow through the vessels of Thebesius and the coronary 
veins. The condition is most commonly seen in the left ventricle and in the 
septum, in the territory of distribution of the anterior coronary artery. The 



* The American Journal of Physiology, vol. i, 1898. 



AFFECTIONS OF THE MYOCARDIUM. 



747 



affected area has a yellowish-white color, sometimes a turbid, parboiled 
aspect, at other times a grayish-red tint. It may be somewhat wedge-shaped, 
more often it is irregular in contour and projects above the surface. Micro- 
scopically the changes are very characteristic. The nuclei either disappear 
from the muscle fibres or they undergo fragmentation. Leucocytes wander 
in from the surrounding tissue, and these may suffer disintegration. At a 
later stage a new growth of fibrous tissue is found in the periphery of the in- 
farct which ultimately may entirely replace the dead fibres. The fibres pre- 
sent a homogeneous, hyaline appearance. In some instances there is com- 
plete transformation, and even to the naked eye a firm white patch of hyaline 
degeneration may appear in the centre of the area. Sudden death not in- 
frequently follows the blocking of one of the branches of the coronary ar- 
tery and the production of this anaemic necrosis. In medico-legal cases it 
is a point of primary importance to remember that this is one of the common 
causes of sudden death. This condition should be carefully sought for, in- 
asmuch as it may be the sole lesion, except a general, sometimes slight 
arterio-sclerosis. Eupture of the heart may be associated with anaemic 
necrosis. 

(b) The second important effect of coronary-artery disease upon the 
myocardium is seen in the production of fibrous myocarditis. This may 
result from the gradual transformation of areas of anaemic necrosis. More 
commonly it is caused by the narrowing of a coronary branch in a process 
of obliterative endarteritis. Where the process is gradual evidences of gran- 
ulation tissue are often wanting, and any distinction between the necrotic 
muscle fibres and the new scar tissue is difficult to establish. J. B. Mac- 
Callum has shown that the muscle fibres undergo a change the reverse of 
that of their normal development and lose their fibril bundles preliminary 
to their complete replacement by connective tissue. The sclerosis is most 
frequently seen at the apex of the left ventricle and in the septum, but it 
may occur in any portion. In the septum and walls there are often streaks 
and patches which are only seen in carefully made systematic sections. 
Hypertrophy of the heart is commonly associated with this degeneration. 
It is the invariable precursor of aneurism of the heart. 

Complete obliteration of one coronary artery, if produced suddenly, is 
usually fatal. When induced slowly, either by arterio-sclerosis at the ori- 
fice of the artery at the root of the aorta or by an obliterating endarteritis 
in the course of the vessel, the circulation may be carried on through the 
other vessel. Sudden death is not uncommon, owing to thrombosis of a 
vessel which has become narrowed by sclerosis. In the most extreme grade 
one coronary artery may be entirely blocked, with the production of ex- 
tensive fibroid disease, and a main branch of the other also may be occluded. 
A large, powerfully built imbecile, aged thirty-five, at the Elwyn Institu- 
tion, Pennsylvania, who had for years enjoyed doing the heavy work about 
the place, died suddenly, without any preliminary symptoms. The heart, 
which is in my collection, weighed over 20 ounces; the anterior coronary 
artery was practically occluded by obliterating endarteritis, and of the 
posterior artery one main branch was blocked. 

(c) Septic Infarcts. — In pyaemia the smaller branches of tho coronary 



748 



DISEASES OF THE CIRCULATORY SYSTEM. 



arteries may be blocked with emboli which give rise to infectious or septic 
infarcts in the myocardium in the form of abscesses, varying in size from 
a pea to a pin's head. These may not cause any disturbance, but when 
large they may perforate into the ventricle or into the pericardium, form- 
ing what has been called acute ulcer of the heart. 

2. Acute Interstitial Myocarditis. — In some infectious diseases and in 
acute pericarditis the intermuscular connective tissue may be swollen and 
infiltrated with small round cells and leucocytes, the blood-vessels dilated, 
and the muscle fibres the seat of granular, fatty, and hyaline degeneration. 
Occasionally, in pyaemia the infiltration with pus-cells has been diffuse and 
confined chiefly to the interstitial tissue. Councilman has described this 
condition of the heart wall in gonorrhoea, and succeeded in demonstrating 
the gonococcus in the diseased areas. The commonest examples are found 
in diphtheria, typhoid fever, and acute endocarditis, as shown by the studies 
of Eomberg. The foci may be the starting-points of patches of fibrous 
myocarditis. 

3. Fragmentation and Segmentation. — This condition was described by 
Renaut and Landouzy in 1877, and has been carefully studied by different 
pathologists.* Two forms are met with: 1. Segmentation. The muscle 
fibres have separated at the cement line. 2. Fragmentation. The fracture 
has been across the fibre itself, and perhaps at the level of the nucleus. 
Longitudinal division is unusual. Although the condition doubtless arises 
in some instances during the death agony, as in cases of sudden death by 
violence, in others it would seem to have clinical and pathological signifi- 
cance. It is found associated with other lesions, fibrous myocarditis, infarc- 
tion, and fatty degeneration. J. B. MacCallum distinguishes a simple from 
a degenerative fragmentation. The first takes place in the normal fibre, 
which, however, shows irregular extensions and contractions. The second 
succeeds degeneration in the fibre. Hearts the seat of marked fragmenta- 
tion are lax, easily torn, the muscle fibres widely separated, and often pale 
and cloudy. 

<±. Parenchymatous Degeneration —This is usually met with in fevers, 
or in connection with endocarditis or pericarditis, and in infections and in- 
toxications generally. It is characterized by a pale, turbid state of the car- 
diac muscle, which is general, not localized. Turbidity and softness are the 
special features. It is the softened heart of Laennec and Louis. Stokes 
speaks of an instance in which " so great was the softening of the organ 
that when the heart was grasped by the great vessels and held with the apex 
pointing upward, it fell down over the hand, covering it like a cap of a 
large mushroom." 

Histologically, there is a degeneration of the muscle fibres, which are 
infiltrated to a various extent with granules which resist the action of ether, 
but are dissolved in acetic acid. Sometimes this granular change in the 
fibres is extreme, and no trace of the striae can be detected. It is probably 
the effect of a toxic agent, and is seen in its most exquisite form in the 
lumbar muscles in cases of toxic haemoglobinuria in the horse. It is met 



* Hektoen, American Journal of the Medical Sciences, 1897. 



AFFECTIONS OF THE MYOCARDIUM. 



749 



with in cases of typhoid, typhus, small-pox, and other infectious diseases, 
particularly when the course is protracted. There is no definite relation 
between it and the high temperature. 

5. Fatty Heart. — Under this term are embraced fatty degeneration and 
fatty overgrowth. 

(a) Fatty degeneration is a very common condition, and mild grades are 
met with in many diseases. It is found in the failing nutrition of old age, 
of wasting diseases, and of cachectic states; in prolonged infectious fevers, 
in which it may follow or accompany the parenchymatous change; associ- 
ated with acute and chronic anaemias. Certain poisons, such as phosphorus, 
produce an intense fatty degeneration. Local causes: Pericarditis is usu- 
ally associated with fatty or parenchymatous changes in the superficial 
layers of the myocardium. Disease of the coronary arteries is a much 
more common cause of fibroid degeneration than of fatty heart. Lastly, in 
the hypertrophied ventricular wall in chronic heart-disease fatty change is 
by no means infrequent. This degeneration may be limited to the heart or 
it may be more or less general in the solid viscera. The diaphragm may 
also be involved, even when the other muscles show no special changes. 
There appears to be a special proneness to fatty degeneration in the heart- 
muscle, which may perhaps be connected with its incessant activity. So 
great is its need of an abundant oxygen supply that it feels at once any de- 
ficiency, and is in consequence the first muscle to show nutritional changes. 

Anatomically the condition may be local or general. The left ventricle 
is most frequently affected. If the process is advanced and general, the 
heart looks large and is flabby and relaxed. It has a light yellowish-brown 
tint, or, as it is called, a faded-leaf color. Its consistence is reduced and 
the substance tears easily. In the left ventricle the papillary columns and 
the muscle beneath the endocardium show a streaked or patchy appearance. 
Microscopically, the fibres are seen to be occupied by minute globules dis- 
tributed in rows along the line of the primitive fibres (Welch). In ad- 
vanced grades the fibres seem completely occupied by the minute globules. 

(b) Fatty Overgroiuth. — This is usually a simple excess of the normal 
subpericardial fat, to which the term cor adiposum was given by the older 
writers. In pronounced instances the fat infiltrates between the muscular 
substance and, separating the strands, may reach even to the endocardium. 
In corpulent persons there is always much pericardial fat. It forms part 
of the general obesity, and occasionally leads to dangerous or even fatal 
impairment of the contractile power of the heart. Of 122 cases analyzed 
by Forchheimer there were 88 males and 34 females. Over 80 per cent 
occurred between the fortieth and seventieth years. 

The entire heart may be enveloped in a thick sheeting of fat through 
which not a trace of muscle substance can be seen. On section, the fat 
infiltrates the muscle, separating the fibres, and in extreme cases — particu- 
larly in the right ventricle — reaches the endocardium. In some places there 
may be even complete substitution of fat for the muscle substance. In 
rare instances the fat may be in the papillary muscles. The heart is usually 
much relaxed and the chambers are dilated. Microscopically the muscle 
fibres may show, in addition to the atrophy, marked fatty degeneration. 



750 



DISEASES OF THE CIRCULATORY SYSTEM. 



6. Other Degenerations of the Myocardium, (a) Brown Atrophy. — 
This is a common change in the heart-muscle, particularly in chronic val- 
vular lesions and in the senile heart. When advanced, the color of the 
muscles is a dark red-brown, and the consistence is usually increased. The 
fibres present an accumulation of yellow-brown pigment chiefly about the 
nuclei. The cement substance is often unusually distinct, but seems more 
fragile than in healthy muscle. 

(b) Amyloid degeneration of the heart is occasionally seen. It occurs 
in the intermuscular connective tissue and in the blood-vessels, not in the 
fibres. 

(c) The hyaline transformation of Zenker is sometimes met with in pro- 
longed fevers. The affected fibres are swollen, homogeneous, translucent, 
and the striae are very faint or entirely absent. 

(d) Calcareous degeneration may occur in the myocardium, and the 
muscle fibres may be infiltrated and yet retain their appearance as figured 
and described by Coats in his Text-book of Pathology. 

Symptoms of Myocardial Disease. — These are notoriously un- 
certain. A man with advanced fibroid myocarditis may drop dead sud- 
denly, while doing heavy work, without having complained of cardiac dis- 
tress. On the other hand, a patient may present enfeebled, irregular action 
and signs of dilatation; he may have shortness of breath, oedema, and the 
general symptoms believed to be characteristic of cases of fibroid and fatty 
heart, and the post mortem show little or no change in the myocardium. 

Cardio-sclerosis or fibroid heart is in some cases characterized by a 
feeble, irregular, slow pulse, with dyspnoea on exertion and occasional at- 
tacks of angina. Irregularity is present in many, but not in all cases. 
The pulse may be very slow, even 30 or 40 per minute. Ultimately the 
cases come under observation with the symptoms of cardiac insufficiency. 
The arrhythmia, which may have been present, becomes aggravated and, 
according to Biegel, may not only precede, but also persist after the car- 
diac insufficiency has passed away. 

Fatty degeneration of the heart presents the same difficulties. Extreme 
fatty changes, as in pernicious anaemia, may be consistent with a full, regular 
pulse and a regularly acting heart. In some of these cases the fat does not 
appear to interfere seriously with the function of the organ. The truth 
is, it may exist in an extreme grade without producing symptoms, so long as 
great dilatation of the chambers does not occur. The cardiac irregularity, 
the dyspnoea, palpitation, and small pulse are in reality not symptoms of 
the fatty degeneration, but of dilatation which has supervened. The fatty 
arcus senilis is of no moment in the diagnosis of fatty heart. The heart- 
sounds may be weak and the action irregular. When dilatation occurs, 
there is often the gallop rhythm, shortening of the long pause, and a sys- 
tolic murmur at the apex. Shortness of breath on exertion is an early 
feature in many cases, and anginal attacks may occur. There is some- 
times a tendency to syncope, and in both fibroid and fatty heart there are 
attacks in which the patient feels cold and depressed and the pulse sinks 
to 40 or 30, or even, as in one case which I saw, to 26. The patient may 
wake from sleep in the early morning with an attack of severe cardiac 



AFFECTIONS OF THE MYOCARDIUM. 



751 



asthma. These " spells " may be associated with nausea and may alter- 
nate with others in which there are anginal symptoms. These are the 
cases, too, in which for weeks there may he mental symptoms. The pa- 
tient has delusions and may even become maniacal. Toward the close, 
the type of breathing known as Cheyne-Stokes may occur. It was described 
in the following terms by John Cheyne, speaking of a case of fatty heart 
(Dublin Hospital Keports, vol. ii, p. 221, 1818): "For several days his 
breathing was irregular; it would entirely cease for a quarter of a minute, 
then it would become perceptible, though very low, then by degrees it be- 
came heaving and quick, and then it would gradually cease again: this 
revolution in the state of his breathing lasted about a minute, during which 
there were about thirty acts of respiration." It is seen much more fre- 
quently in arterio-sclerosis and uraemic states than in fatty heart. 

Fatty overgrowth of the heart is a condition certain to exist in very 
obese persons. It produces no symptoms until the muscular fibre is so 
weakened that dilatation occurs. These patients may for years present a 
feeble but regular pulse; the heart-sounds are weak and muffled, and a 
murmur may be heard at the apex. Attacks of cardiac asthma are not 
uncommon, and the patient may surfer from bronchitis. Dizziness and 
pseudo-apoplectic seizures may occur. Sudden death may result from syn- 
cope or from rupture of the heart. The physical examination is often diffi- 
cult because of tho great increase in the fat, and it may be impossible to 
define the area of dulness. 

For clinical purposes we may group the cases of myocardial disease as 
follows: 

(1) Those in which sudden death occurs with or without previous indi- 
cations of heart-trouble. Sclerosis of the coronary arteries exists — in some 
instances with recent thrombus and white infarcts; in others, extensive 
fibroid disease; in others again, fatty degeneration. Many patients never 
complain of cardiac distress, but, as in the case of Chalmers, the celebrated 
Scottish divine, enjoy unusual vigor of mind and body. 

(2) Cases in which there are cardiac arrhythmia, shortness of breath on 
exertion, attacks of cardiac asthma, sometimes anginal attacks, collapse 
symptoms with sweats and extremely slow pulse, and occasionally marked 
mental symptoms. 

(3) Cases with general arterio-sclerosis and hypertrophy and dilatation 
of the heart. They are robust men of middle age who have worked hard 
and lived carelessly. Dyspnoea, cough, and swelling of the feet are the early 
symptoms, and the patient comes under observation either with a gallop 
rhythm, embryocardiac, or an irregular heart with an apex systolic murmur 
of mitral insufficiency. Recovery from the first or second attack is the rule. 
It is one of the most common forms of heart-disease. 

Prognosis. — The outlook in affections of the myocardium is extreme- 
ly grave. Patients recover, however, in a surprising way Prom the most 
serious attacks, particularly those of the third group. 

Treatment. — Many cases never come under treatment; the first are 
the final symptoms. 

Cases with signs of well-marked cardiac insufficiency, as manifested by 
dyspnoea, weak, irregular, rapid heart, and oedema, may be treated on the 
47 ' 



752 



DISEASES OF THE CIRCULATORY SYSTEM. 



plan laid down for the treatment of broken compensation in valvular dis- 
ease. Digitalis may be given even if fatty degeneration is suspected, and 
is often very beneficial. 

Much more difficult is the management of those cases in which there 
is marked cardiac arrhythmia, with a feeble, irregular, very slow pulse, and 
syncope or angina. Dropsy is not, as a rule, present; the heart-sounds may 
be perfectly clear, and there are no signs of dilatation. Digitalis, under 
these circumstances, is not advisable, particularly when the pulse is infre- 
quent. Complete rest in bed, a carefully regulated diet, and the use of the 
aromatic spirits of ammonia, sulphuric ether, and stimulants are indicated. 
For the restlessness and distressing feelings of anxiety morphia is invalu- 
able. From an eightieth to a sixtieth of a grain of strychnia may be given 
three times a day. If, as is sometimes the case, the pulse is hard and firm, 
nitroglycerin may be cautiously administered, beginning with 1 minim of 
the 1-per-cent solution three times a day and increased gradually. 

In certain cases of weak heart, particularly when it is due to fatty over- 
growth, the plans recommended by Oertel and by Schott are advantageous. 
They are invaluable methods in those forms of heart-weakness due to in- 
temperance in eating and drinking and defective bodily exercise. The 
Oertel plan consists of three parts: First, the reduction in the amount of 
liquid. This is an important factor in reducing the fat in these patients. 
It also slightly increases the density of the blood. Oertel allows daily about 
36 ounces of liquid, which includes the amount taken with the solid food. 
Free perspiration is promoted by bathing (if advisable, the Turkish bath), 
or even by the use of pilocarpine. 

The second important point in his treatment is the diet, which should 
consist largely of proteids. 

Morning. — Cup of coffee or tea, with a little milk, about 6 ounces alto- 
gether. Bread, 3 ounces. 

Noon. — Three to 4 ounces of soup, 7 to 8 ounces of roast beef, veal, 
game, or poultry, salad or a light vegetable, a little fish; 1 ounce of bread 
or farinaceous pudding; 3 to 6 ounces of fruit for dessert. ~No liquids at 
this meal, as a rule, but in hot weather 6 ounces of light wine may be taken. 

Afternoon. — Six ounces' of coffee or tea, with as much water. As an 
indulgence an ounce of bread. 

Evening. — One or 2 soft-boiled eggs, an ounce of bread, perhaps a small 
slice of cheese, salad, and fruit; 6 to 8 ounces of wine with 4 or 5 ounces of 
water (Yeo). 

The most important element of all is graduated exercise, not on the 
level, but up hills of various grades. The distance walked each day is 
marked off and is gradually lengthened. In this way the heart is systemat- 
ically exercised and strengthened. 

The Schott Treatment. — This consists in a combination of baths with 
exercises at Nauheim. The water has a temperature of from 82°-95° F., 
and is very richly charged with C0 2 . The good effects of the bath are 
claimed by Schott to come from a cutaneous excitation, induced by the 
mineral and gaseous constituents of the bath, and a stimulation of the 
sensory nerves. There is no question that the bath, in suitable cases, will 



AFFECTIONS OF THE MYOCARDIUM. 



753 



alter the position of the apex beat, and that it lessens the area of cardiac 
dulness; this means that it diminishes the dilatation of the heart. Artificial 
baths are used, consisting of forty gallons of water, with various strengths 
of sodium chloride and calcium chloride. The exercises, resistance gym- 
nastics, consist in slow movements executed by the patient and resisted 
by the operator. Any one wishing to carry out in private the Schott treat- 
ment should consult the work of Besley Thorne. Camac's articles (J. H. 
H. Bulletin, vol. viii, and Jour, of the Am. Med. Assoc., 1897, ii) give a 
brief account of our experience with it. 

Aneurism of the Heart. 

(a) Aneurism of a valve results from acute endocarditis, which pro- 
duces softening or erosion and may lead either to perforation of the seg- 
ment or to gradual dilatation of a limited area under the influence of the 
blood-pressure. The aneurisms are usually spheroidal and project from 
the ventricular face of a sigmoid valve. They are much less common on 
the mitral segments. They frequently rupture and produce extensive de- 
struction and incompetency of the valves. 

(b) Aneurism of the walls results from the weakening induced by 
chronic myocarditis, or occasionally it follows acute mural endocarditis, 
which more commonly, however, leads to perforation. It has followed a 
stab-wound, a gumma of the ventricle, and, according to some authors, peri- 
cardial adhesions. The left ventricle near the apex is usually the seat, this 
being the situation in which fibrous degeneration is most common. Fifty- 
nine of the 60 cases collected by Legg were situated here. In the 
early stages the anterior wall of the ventricle, near the septum, sometimes 
even the septum itself, is slightly dilated, the endocardium opaque, and 
the muscular tissue sclerotic. In a more advanced stage the dilatation is 
pronounced and layers of thrombi occupy the sac. Ultimately a large 
rounded tumor may project from the ventricle and may attain a size equal 
to that of the heart. Occasionally the aneurism is sacculated and com- 
municates with the ventricle through a very small orifice. The sac may be 
double, as in the cases of Janeway and Sailer. In the museum of Guy's 
Hospital there is a specimen showing the wall of the ventricle covered with 
aneurismal bulgings. Rupture occurred in 7 of the 90 cases collected by 
Le gg- 

The symptoms produced by aneurism of the heart are indefinite. Occa- 
sionally there is marked bulging in the apex region and the tumor may per- 
forate the chest wall. In mitral stenosis the right ventricle may bulge and 
produce a visible pulsating tumor below the left costal border, which I have 
known to be mistaken for cardiac aneurism. When the sac is large and 
produces pressure upon the heart itself, there may be a marked disproportion 
between the strong cardiac impulse and the feeble pulsation in the periph- 
eral arteries. 

Rupture of the Heart. 

This rare event is usually associated with fatty infiltration or degenera- 
tion of the heart-muscles. In some instances, acute softening in conse- 



754 



DISEASES OP THE CIRCULATORY SYSTEM. 



quence of embolism of a branch, of the coronary artery, suppurative myo- 
carditis, or a gummatous growth has been the cause. Of 100 cases col- 
lected by Quain, fatty degeneration was noted in 77. Two thirds of the 
patients were over sixty years of age. 

The rent may occur in any of the chambers, but is found most fre- 
quently in the left ventricle on the anterior wall, not far from the septum. 
The accident usually takes place during exertion. There may "be no pre- 
liminary symptoms, but without any warning the patient may fall and die 
in a few moments. Sudden death occurred in 71 per cent of Quain's cases. 
In other instances there may be in the cardiac region a sense of anguish and 
suffocation, and life may be prolonged for several hours. In a Montreal 
case, which I examined, the patient walked up a steep hill after the onset of 
the symptoms, and lived for thirteen hours. A case is on record in which 
the patient lived for eleven days. 

New Growths and Parasites. 

Tubercle and syphilis have already been considered. Primary cancer 
or sarcoma is extremely rare. Secondary tumors may be single or mul- 
tiple, and are usually unattended with symptoms, even when the disease 
is most extensive. In one case I found in the wall of the right ventricle 
a mass which involved the anterior segment of the tricuspid valve and 
partly blocked the orifice. The surface was eroded and there were numer- 
ous cancerous emboli in the pulmonary artery. In another instance the 
heart was greatly enlarged, owing to the presence of innumerable masses of 
colloid cancer the size of cherries. The mediastinal sarcoma may penetrate 
the heart, though it is remarkable how extensive the disease of the medias- 
tinal glands may be without involvement of the heart or vessels. 

Cysts in the heart are rare. They are found in different parts, and 
are filled either with a brownish or a clear fluid. Blood-cysts occasionally 
occur. 

The parasites have been discussed under the appropriate section, but it 
may be mentioned here that both the cysticerus cellulosce and the echino- 
coccus cysts occur occasionally in the heart. 

Wounds and Foreign Bodies. 

Wounds of the heart may be caused by external injuries, as stabs and 
bullet wounds, by foreign bodies passing from the gullet or oesophagus, or 
by puncture for therapeutic purposes. 

(1) Bullet wounds of the heart are common. Recovery may take place, 
and bullets have been found encysted in the organ. Stab wounds are still 
more common. A medical student, while on a spree, passed a pin into 
his heart. The pericardium was opened, and the head of the pin was found 
outside of the right ventricle. It was grasped and an attempt made to 
remove it, but it was withdrawn into the heart and, it is said, caused the 
patient no further trouble (Moxon). In recent stab wounds it is a good 
practice to expose the heart and attempt to suture the wound. Hill, of 



NEUROSES OF THE HEART. 



755 



Montgomery, Ala., has collected 17 operations for suture, of which 7 re- 
covered. Not only has the heart been sutured, but in a case of stab' wound 
Pagenstecher tied the left coronary artery, which had been divided. 

(2) Hysterical girls sometimes swallow pins and needles, which, passing 
through the oesophagus and stomach, are found in various parts of the 
body. A remarkable case is reported by Allen J. Smith of a girl from 
whom several dozen needles and pins were removed, chiefly from subcu- 
taneous abscesses. Several years later she developed symptoms of chronic 
heart-disease. At the post mortem needles were found in the tissues of 
the adherent pericardium, and between thirty and forty were embedded in 
the thickened pleural membranes of the left side. 

(3) Puncture of the heart (cardiocentesis) has been recommended as a 
therapeutic procedure, as in chloroform narcosis, and experimental evi- 
dence has been brought forward by B. A. Watson in favor of the operation. 
He advises abstraction of blood in combination with the puncture — car- 
diocentesis. The proceeding is not without risk. Haemorrhage may take 
place from the puncture, though it is not often extensive. Sloane has re- 
cently urged its use in all cases of asphyxia and in suffocation by drowning 
and from coal-gas. The successful case which he reports illustrates forcibly 
its stimulating action. 

V. NEUROSES OF THE HEART. 

Palpitation. 

In health we are unconscious of the action of the heart. In some people 
one of the first indications of debility or overwork is the consciousness of 
the cardiac pulsations, which may, however, be perfectly regular and or- 
derly. This is not palpitation. The term is properly limited to irregular 
or forcible action of the heart perceptible to the individual. 

Etiology. — The expression " perceptible to the individual " covers 
the essential element in palpitation of the heart. The most extreme dis- 
turbance of rhythm, a condition even of what is termed delirium cordis, 
may be unattended with subjective sensations of distress, and there may 
be no consciousness of disturbed action. On the other hand, there are 
cases in which complaint is made of the most distressing palpitation and 
sensations of throbbing, in which the physical examination reveals a regu- 
larly acting heart, the sensations being entirely subjective. We meet with 
this symptom in a large group of cases in which there is increased excita- 
bility of the nervous system. Palpitation may be a marked feature at the 
time of puberty, at the climacteric, and occasionally during menstruation. 
It is a very common symptom in hysteria and neurasthenia, particularly in 
the form of the latter which is associated with dyspepsia. Emotions, such 
as fright, are common causes of palpitation. It may occur as a sequence of 
the acute fevers. Females are more liable to the affection than males. 

In a second group the palpitation results from the action upon the 
heart of certain substances, such as tobacco, coffee, tea, and alcohol. And, 
lastly, palpitation may be associated with organic disease of the heart, 
either of the myocardium or of the valves. As a rule, however, it is a 



756 



DISEASES OP THE CIRCULATORY SYSTEM. 



purely nervous phenomenon — seldom associated with organic disease — in 
which the most violent action and the most extreme irregularity may exist 
without that subjective element of consciousness of the disturbance which 
constitutes the essential feature of palpitation. 

The irritable heart described by Da Costa, which was so common among 
the young soldiers during the civil war, is a neurosis of this kind. The 
chief symptoms were palpitation with great frequency of the pulse on ex- 
ertion, a variable amount of cardiac pain, and dyspnoea. The factors at 
work in producing this condition appeared to be the mental excitement, 
the unwonted muscular exertion associated with the drill, and diarrhoea. 
The condition is not infrequent in civil life among young men, and it leads 
in some cases to hypertrophy of the heart. 

Symptoms. — In the mildest form, such as occurs during a dyspeptic 
attack, there is slight fluttering of the heart and a sense of what patients 
sometimes call " goneness." In more severe attacks the heart beats vio- 
lently, its pulsations against the chest wall are visible, the rapidity of the 
action is much increased, the arteries throb forcibly, and there is a sense 
of great distress. In some instances the heart's action is not at all quick- 
ened. The most striking cases are in neurasthenic women, in whom the 
mere entrance of a person into the room may cause the most violent action 
of the heart and throbbing of the peripheral arteries. The pulse may be 
rapidly increased until it reaches 150 or 160. A diffuse flushing of the 
skin may appear at the same time. After such attacks, there may be the 
passage of a large quantity of pale urine. In many cases of palpitation, 
particularly in young men, the condition is at once relieved by exertion. 
A patient with extreme irregularity of the heart may, after walking quickly 
100 yards or running upstairs, return with the pulse perfectly regular. 
This is not infrequently seen, too, in the irregular action of the heart in 
mitral valve disease. 

The physical examination of the heart is usually negative. The sounds, 
the shock of which may be very palpable, are on auscultation clear, ringing, 
and metallic, but not associated with murmurs. The second sound at the 
base may be greatly accentuated. A murmur may sometimes be heard 
over the pulmonary artery or even at the apex in cases of rapid action in 
neurasthenia or in severe anaemia. The attacks may be transient, lasting 
only for a few minutes, or may persist for an hour or more. In some in- 
stances any attempt at exertion renews the attack. 

The prognosis is usually good, though it may be extremely difficult to 
remove the conditions underlying the palpitation. 

Aeehythmia. 

An intermission occurs when one or more beats of the heart are dropped. 
Irregularity is the condition when the beats are unequal in volume and 
force, or follow each other at unequal distances. Allorrhythmia is a term 
which is also used to express deviations from the normal heart rhythm. 
The following varieties of arrhythmical action may be recognized: 
(1) The paradoxical pulse of Kussmaul, in which the beats during in- 



NEUROSES OF THE HEART. 



757 



spiration are more frequent but less full than during expiration. This is 
found in weak heart, in chronic pericarditis, and when fibrous bands en- 
circle the root of the aorta; but it may also occur normally from the influ- 
ence of the respirations upon the heart. It is sometimes to be felt in sleeping 
children. 

(2) Intermittence, in which there is simply an intermission or dropping 
of a cardiac beat. The term deficience is more correctly applied to those 
instances in which the absence of the heart-sound proves that the systole 
is really omitted. The systole may be so weak as not to produce a pulsa- 
tion, and yet at the same time a feeble first sound may be heard. 

(3) The alternate heart-beat, in which strong and weak contractions 
alternate regularly and which is expressed in the peripheral arteries by 
alternate full and feeble pulse-beats. 

(4) The bigeminal and trigeminal pulsations occur when two or three 
beats follow each other in rapid succession, each group being separated 
from the following by a longer interval. This is not very uncommon in 
mitral disease and as an effect of digitalis. In the bigeminal pulse the 
first beat of the pair is usually the stronger. Indeed, in the condition 
known as heart bigeminism the second systole is so feeble that the pulse 
wave does not reach the peripheral arteries and the two systoles are repre- 
sented by only a single pulse-beat at the wrist. 

(5) Delirium cordis, in which these various factors are combined and 
the heart's action is wholly irregular. 

(6) Foetal heart rhythm — embryocardia — described by Stokes, is a very 
common condition in which the long pause is shortened and the charac- 
ters of the sounds are " almost completely identical." The resemblance 
to the foetal heart-beat is very striking. In the later stages of fevers 
and in extreme dilatation this form of heart rhythm is very frequently 
heard. 

(7) Gallop rhythm, in which the sounds resemble the footfall of a horse 
at canter, usually results from the reduplication of the sounds in a rapidly 
acting heart. It is expressed by the words " rat-ta-tat." Sometimes it 
seems as if the first sound was split; more commonly it is the second. 
It is most frequently heard in the failing heart of interstitial nephritis and 
arterio-sclerosis. Its mode of origin has been much discussed, and it is 
doubtful whether a satisfactory explanation has yet been given. As Graham 
Steell states, its presence indicates muscle weakness. It is interesting among 
disturbances of rhythm as the only one which we can see and feel as well 
as hear. 

The causes of these various disturbances of rhythm are thus classified 
by G. Baumgarten: * 

(1) Those due to central — cerebral — causes, either organic disease, as 
in haemorrhage, or concussion; more commonly psychical influences. 

(2) Reflex influences, such as produce the cardiac irregularity in dys- 
pepsia and diseases of the liver, lungs, and kidneys. 

(3) Toxic influences. Tobacco, coffee, and tea are common causes of 



Transactions of the Association of American Physicians, vol. iii. 



758 



DISEASES OP THE CIRCULATORY SYSTEM. 



arrhythmia. Various drugs, such as digitalis, belladonna, and aconite, 
may also induce it. 

(4) Changes in the heart itself, (a) In the cardiac ganglia. Fatty, 
pigmentary, and sclerotic changes have been described in cases of this 
sort and may have an important influence in producing disturbances in the 
rhythm; but as yet we do not know their exact significance. They may 
be present in cases which have not presented arrhythmia, (b) Mural changes 
are common in conditions of this kind. Simple dilatation, fatty degenera- 
tion, and sclerosis are most commonly present, the two latter usually asso- 
ciated with sclerosis of the coronary arteries. 

The significance of arrhythmia is not always easy to determine. Simple 
irregular action of the heart may persist for years. The late Chancellor 
Ferrier, of McGill University, a man of unusual bodily and mental vigor, 
who died at the age of eighty-seven, had an extremely irregular pulse for, 
almost fifty years of his life. One or two other instances have come under 
my notice of persons in good health, without arterial or cardiac disease, in 
whom the heart's action was persistently irregular. The bigeminal and 
trigeminal pulsations are found more frequently in mitral than in other 
conditions. The delirium cordis is met with in the dilatation associated 
with valvular lesions, particularly toward the latter stages, Fcetal heart 
rhythm is rarely found apart from dilatation. 

Eapid Heaet — Tachycaedia. 

The rapid action may be perfectly natural. There are individuals 
whose normal heart action is at 100 or even more per minute. It may 
be caused by the various conditions which induce palpitation; but the 
two are not necessarily associated. Emotional causes, violent exercise, and 
fevers all produce great increase in the rapidity of the heart's action. The 
extremely rapid action which follows fright may persist for days, or even 
weeks. Traube reports an instance in which, after violent exercise, the 
rapidity of the heart continued. Cases are not uncommon at the meno- 
pause. 

There are cases again in which the condition can hardly be termed a 
neurosis, since it depends upon definite changes in the pneumogastrics 
or in the medulla. Cases have been reported in which tumor or clot in 
or about the medulla or pressure upon the vagi has been associated with 
heart hurry. Some of the cases of frequent action of the heart in women 
have been thought to be due to reflex irritation from ovarian or uterine 
disease. 

Paroxysmal tachycardia is a remarkable affection, characterized by spells 
of heart hurry, during which the action is greatly increased, the pulse 
reaching 200 and over. The cases are not common. The condition has 
been thoroughly studied by Nothnagel. The attack may be quite short 
and persist only for an hour or so. A patient at the Philadelphia Infirmary 
for Nervous Diseases was attacked every week or two; the pulse would rise 
to 220 or 230, and there were such feelings of distress and uneasiness that 
the patient always had to lie down. There may be, however, no subjective 



NEUROSES OF THE HEART. 



T59 



disturbance, and in another case the patient was able to walk about during 
the paroxysm and had no dyspnoea. One of the most remarkable cases is 
reported by H. C. Wood. A physician in his eighty-seventh year had had 
attacks at intervals since his thirty-seventh year. The onset was abrupt and 
the pulse would rapidly rise to 200 a minute. For more than twenty years 
the taking of ice-water or strong coffee would arrest the attacks. Bouveret 
has analyzed a number of cases of this essential or idiopathic form; he 
finds that a permanent cure is rare, and that the patients suffer for ten 
or more years. Four instances terminated fatally from heart-failure. Mar- 
tius looks upon it as a symptom of an acute dilatation of the heart, appear- 
ing paroxysmally. Wood suggests that these cardiac paroxysms are caused 
by discharging lesions affecting the centres of the accelerator nerves. 
Frangois Franck has shown that the acceleration of the heart's action is 
due to the shortening of the diastole, and during the systole so little blood 
is expelled from the heart that the average amount in the minute is not 
increased. Moreover, the accelerators appear to have no trophic relation 
to the heart, and stimulation of them is not accompanied either by in- 
creased arterial pressure or by augmentation of the work done by the heart. 

Slow Heart — Brachycardia {Bradycardia). 

Slow action of the heart is sometimes normal and may be a family pecul- 
iarity. Napoleon is stated to have had a pulse of only 40 per minute. 

In any case of slow pulse it is important first to make sure that the 
number of heart and arterial beats correspond. In many instances this is 
not the case, and with a radial pulse at 40 the cardiac pulsations may be 
80, half the beats not reaching the wrist. The heart contractions, not the 
pulse wave, should be taken into account. A most exhaustive study of 
this condition has been made by Eiegel, whose division is here followed: 

(a) Physiological brachycardia. In the puerperal state the pulse may 
beat from 44 to 60 per minute, or may even be as low as 34. It is seen in 
premature labor as well as at term. The explanation of its occurrence at 
this period is not clear. Slowness of the pulse is associated with hunger. 
Brachycardia depending on individual peculiarity is extremely rare. 

(b) Pathological brachycardia, which is met with under the following 
conditions: (1) In convalescence from acute fevers. This is extremely 
common, particularly after pneumonia, typhoid fever, acute rheumatism, 
and diphtheria. It is most frequently seen in young persons and in cases 
which have run a normal course. Traube's explanation that it is due to 
exhaustion is probably the correct one. (2) In diseases of the digestive 
system, such as chronic dyspepsia, ulcer or cancer of the stomach, and 
jaundice. The largest number of Riegel's cases were of this group. (3) 
In diseases of the respiratory system. Here it is by no means so common, 
but is seen not infrequently in emphysema. (4) In diseases of the circu- 
latory system. Excluding all cases of irregularity of the heart, brachv- 
eardia is not common in diseases of the valves. It is most frequently seen 
in fatty and fibroid changes in the heart, but is not constant in them. (•")) 
In diseases of the urinary organs. It occurs occasionally in nephritis and 



760 



DISEASES OF THE CIRCULATORY SYSTEM. 



may be a feature of uraemia. (6) From the action of toxic agents. It occurs 
in uraamia, poisoning by lead, alcohol, and follows the use of tobacco, 
coffee, and digitalis. (7) In constitutional disorders, such as anaemia, 
chlorosis, and diabetes. (8) In diseases of the nervous system. Apoplexy, 
epilepsy, the cerebral tumors, affections of the medulla, and diseases and 
injuries of the cervical cord may be associated with very slow pulse. In 
general paresis, mania, and melancholia it is not infrequent. (9) It occurs 
occasionally in affections of the skin and sexual organs, and in sunstroke, 
or in prolonged exhaustion from any cause. 

The Stokes-Adams Syndrome. — Slow Pulse with Syncopal Attacks. — 
Eobert Adams and Stokes described a remarkable condition in which the 
pulse was permanently slow in association with attacks of syncope. The 
patients are usually advanced in years and show an extreme grade of arterio- 
sclerosis. The pulse-rate may be 30 or 20 to the minute, or, as in Prentice's 
case, as low as 12, or even 10 or 5. The cerebral symptoms are very re- 
markable, and Stokes suggested for them the name of false or pseudo- 
apoplexy. Attacks of vertigo, which may recur several times in the day, 
attacks of syncope, in which the patient is insensible for four or five min- 
utes, or epileptiform attacks, as in Ogle's cases, are the most pronounced 
cerebral symptoms. Huchard regards the condition as the result of changes 
in the pneumogastric centres due to disease of the arteries of the medulla. 
(See Lecture IV in my monograph on Angina Pectoris and Allied States.) 

Treatment of Palpitation and Arrhythmia. — An important 
element in many cases is to get the patient's mind quieted, and he can be 
assured that there is no actual danger. The mental element is oftentimes 
very strong. In palpitation, before using medicines, it is well to try the 
effect of hygienic measures. As a rule, moderate exercise may be taken 
with advantage. Regular hours should be kept, and at least ten hours 
out of the twenty-four should be spent in the recumbent posture. A tepid 
bath may be taken in the morning, or, if the patient is weakly and nerv- 
ous, in the evening, followed by a thorough rubbing. Hot baths and the 
Turkish bath should be avoided. The dietetic management is most im- 
portant. It is best to prohibit absolutely alcohol, tea, and coffee. The 
diet should be light and the patient should avoid taking large meals. Arti- 
cles of food known to cause flatulency should not be used. If a smoker, 
the patient should give up tobacco. Sexual excitement- is particularly 
pernicious, and the patient should be warned specially on this point. For 
the distressing attacks of palpitation which occur with neurasthenia, par- 
ticularly in women, a rigid Weir Mitchell course is the most satisfactory. 
It is in these cases that we find the most distressing throbbing in the abdo- 
men, which is apt to come on after meals, and is very much aggravated 
by flatulency. The cases of palpitation due to excesses or to errors in diet 
and dyspepsia are readily remedied by hygienic measures. 

A course of iron is often useful. Strychnia is particularly valuable, 
and is perhaps best administered as the tincture of nux vomica in large 
doses. Very little good is obtained from the smaller quantities. It should 
be given freely, 20 minims three times a day. 

If there is great rapidity of action, aconite may be tried or veratrum 



NEUROSES OF THE HEART. 



761 



viride. There are cases associated with sleeplessness and restlessness which 
are greatly benefited by bromide of potassium. Digitalis is very rarely 
indicated^ but in obstinate cases it may be tried with the nux vomica. 

Cases of heart hurry are often extremely obstinate, as may be judged 
from the case of the physician reported by H. C. Wood, in whom the con- 
dition persisted in spite of all measures for fifty years. The bromides are 
sometimes useful; the general condition of neurasthenia should be treated, 
and during the paroxysm an ice-bag may be placed upon the heart, or 
Leiter's coil, through which ice-water may be passed. Electricity, in the 
form of galvanism, is sometimes serviceable, and for its mental effect the 
Franklinic current. For the condition of slow pulse but little can be done. 
A great majority of the cases are not dangerous. 

Angina Pectoris. 

Stenocardia, or the breast-pang, described by Heberden, is not an inde- 
pendent affection, but a symptom associated with a number of morbid 
conditions of the heart and vessels, more particularly with sclerosis of 
the root of the aorta and changes in the coronary arteries. True angina, 
which is a rare disease, is characterized by paroxysms of agonizing pain 
in the region of the heart, extending into the arms and neck. In violent 
attacks there is a sensation of impending death. 

Etiology. — It is a disease of adult life and occurs almost exclusively 
in men. In Huchard's statistics of 237 cases only 42 were in women. In my 
series of 40 cases there was only one woman. It may occur through several 
generations, as in the Arnold family. Gout, diabetes, and syphilis are im- 
portant factors. A number of cases of angina pectoris have followed influ- 
enza. Attacks are not infrequent in certain forms of heart-disease, par- 
ticularly aortic insufficiency and adherent pericardium. It is much less 
common in disease of the mitral valve. Almost without exception the sub- 
jects of true angina have arterio-sclerosis, either general or localized at the 
root of the aorta, with changes in the coronary arteries and in the myo- 
cardium. 

Phenomena of the Attack. — The exciting cause is in a majority of all 
cases well defined. In only rare instances do the patients have attacks when 
quiet. They come on during exertion most frequently, as in walking up hill 
or doing something entailing sudden muscular effort; occasionally even the 
effort of dressing or of stooping to lace the shoes may bring on a paroxysm. 
Mental emotion is a second very potent cause. John Hunter appreciated 
this when he said that " his life was in the hands of any rascal who chose 
to annoy and tease him." In his case a fatal attack occurred during a fit 
of anger. A third, and in many instances the most important, factor is 
flatulent distention of the stomach. Another common exciting cause is 
cold; even the chill of getting out of bed in the morning or on bathing 
may bring on a paroxysm. 

Usually during exertion or intense mental emotion the patient is seized 
with an agonizing pain in the region of the heart and a sense of constric- 
tion, as if the heart had been seized in a vice. The pains radiate up the 



762 



DISEASES OF THE CIRCULATORY SYSTEM. 



neck and down the arm, and there may be numbness of the fingers or in 
the cardiac region. The face is usually pallid and may assume an ashy- 
gray tint, and not infrequently a profuse sweat breaks out over the surface. 
The paroxysm lasts from several seconds to a minute or two, during which, 
in severe attacks, the patient feels as if death were imminent. As pointed 
out by Latham, there are two elements in the paroxysm, the pain — dolor 
pectoris — and the indescribable feeling of anguish and sense of imminent 
dissolution — angor animi. There are great restlessness and anxiety, and 
the patient may drop dead at the height of the attack or faint and pass away 
in syncope. The condition of the heart during the attack is variable; the 
pulsations may be uniform and regular. The pulse tension, however, is 
usually increased, but it is surprising, even in cases of extreme severity,, 
how slightly the character of the pulse may be altered. After the attack 
there may be eructations, or the passage of a large quantity of clear urine. 
The patient usually feels exhausted, and for a day or two may be badly 
shaken; in other instances in an hour or two the patient feels himself 
again. While dyspnoea is not a constant feature, the paroxysm is not infre- 
quently associated with a form of asthma; there is wheezing in the bron- 
chial tubes, which may come on very rapidly, and the patient gets short of 
breath. Many patients the subjects of angina die suddenly without warn- 
ing and not in a paroxysm. In other instances death follows in the first 
well-marked paroxysm, as in the case of Thomas Arnold. In a third group 
there are recurring attacks over long periods of years, as in John Hunter's 
case; while in a fourth group of cases there are rapidly recurring attacks 
for several days in succession, with progressive and increasing weakness 
of the heart. 

With reference to the radiation of pain in angina, the studies of Mac- 
kenzie and of Head are of great interest. Head concludes that (1) in dis- 
eases of the heart, and more particularly in aortic disease, the pain is re- 
ferred along the first, second, third, and fourth dorsal areas; (2) in angina 
pectoris the pain may be referred in addition along the fifth, sixth, and 
seventh, and even the eighth and ninth dorsal areas, and is always accom- 
panied by pain in certain cervical areas. 

Theories of Angina Pectoris. — (1) That it is a neuralgia of the cardiac 
nerves. In the true form the agonizing cramp-like character of the pain, 
the suddenness of the onset, and the associated features, are unlike any 
neuralgic affection. The pain, however, is undoubtedly in the cardiac 
plexus and radiates to adjacent nerves. It is interesting to note, in con- 
nection with the almost constant sclerosis of the coronary arteries in an- 
gina, that Thoma has found marked sclerosis of the temporal artery in 
migraine and Dana has met with local thickening of the arteries in some 
cases of neuralgia. (2) Heberden believed that it was a cramp of the heart- 
muscle itself. Cramp of certain muscular territories would better ex- 
plain the attack. (3) That it is due to the extreme tension of the ven- 
tricular walls, in consequence of an acute dilatation associated, in the ma- 
jority of cases, with affection of the coronary arteries. Traube, who sup- 
ported this view, held that the agonizing pain resulted from the great 
stretching and tension of the nerves in the muscular substance. A modi- 



NEUROSES OF THE HEART. 



763 



fled form of this view is that there is a spasm of the coronary arteries with 
great increase of the intracardiac pressure. 

(4) The theory of Allan Burns, revived by Potain and others, that the 
condition is one of transient ischaemia of the heart-muscle in consequence 
of disease, or spasm, of the coronary arteries. The condition known as 
intermittent claudication illustrates what may take place. "In man (and 
in the horse), in consequence of thrombosis of the abdominal aorta or 
iliacs, transient paraplegia and spasm may follow exertion. The collateral 
circulation, ample when the limbs are at rest, is insufficient after the mus- 
cles are actively used, and a state of relative ischaemia is induced with loss 
of power, which disappears in a short time. This " intermittent claudica- 
tion " theory has been applied to explain the angina paroxysm. A heart 
the coronary arteries of which are sclerotic or calcified, is in an analogous 
state, and any extra exertion is likely to be followed by a relative ischaemia 
and spasm. In Allan Burns's work on The Heart (1809) the theory is dis- 
cussed at length, but he does not think that spasm is a necessary accom- 
paniment of the ischaemia. 

In fatal cases of angina the coronary arteries are almost invariably dis- 
eased either in their main divisions, or there is chronic endarteritis with 
great narrowing of the orifices at the root of the aorta. Experimentally, 
occlusion of the coronary arteries produces slowing of the heart's action, 
gradual dilatation, and death within a very few minutes. Cohnheim has 
shown that in the dog ligation of one of the large coronary branches pro- 
duces within a minute a condition of arrhythmia, and within two minutes 
the heart ceases in diastole. These experiments, however, do not throw 
much light upon the etiology of angina pectoris. Extreme sclerosis of the 
coronary arteries is common, and a large majority of the cases present no 
symptoms of angina. Even in the cases of sudden death due to blocking 
of an artery, particularly the anterior branch of the coronary artery, there 
is usually no great pain either before or during the attack. 

Diagnosis. — There are many grades of true angina. A man may have 
slight praecordial pain, a sense of distress and uneasiness, and radiation of 
the pains to the arm and neck. Such attacks following slight exertion, an 
indiscretion in diet, or a disturbing emotion, may alternate with attacks 
of much greater severity, or they may occur in connection with a pulse of 
increased tension and signs of general arterio-sclerosis. In the milder 
grades the diagnosis cannot rest upon the symptoms of the attack itself, 
since they may be simulated by the pseudo-angina; but the diagnosis should 
be based upon the examination of the heart and arteries and a careful con- 
sideration of the mode of onset and symptoms. The cases of pseudo-angina 
pectoris in women are, after all, the ones which call for the greatest care 
in the diagnosis, and attention to the points given in the table of Iluchard 
will be of the greatest aid. 

Pseudo-Angina Pectoris. — False angina may be divided into two main 
groups, the neurotic and the toxic. The former embraces the hysterical 
and neurasthenic cases, which are very common in women. Iluchard has 
given an excellent differential table between the true and the spurious at- 
tacks. 



764 



DISEASES OF THE CIRCULATORY SYSTEM. 



TKUE ANGINA. PSEUDO-ANGINA. 

Most common between the ages At every age, even six years, 
of forty and fifty years. 

Most common in men. Attacks Most common in women. At- 

brought on by exertion. tacks spontaneous. 

Attacks rarely periodical or noc- Often periodical and nocturnal, 
turnal. 

Not associated with other symp- Associated with nervous symp- 
toms, toms. 

Vaso-motor form rare. Agoniz- Yaso-motor form common. Pain 

ing pain and sensation of compres- less severe; sensation of distention, 
sion by a vice. 

Pain of short duration. Atti- Pain lasts one or two hours. Agi- 

tude: silence, immobility. tation and activity. 

Lesions : sclerosis of coronary Neuralgia of nerves and cardio- 

artery. . plexus. 

Prognosis grave, often fatal. Never fatal. 

Arterial medication. Antineuralgic medication. 

A form which Nothnagel has described as vaso-motor angina is not infre- 
quent. The symptoms set in with coldness and numbness in the extremi- 
ties, followed by great precordial pain and feelings of faintness. Some 
have recognized also a reflex variety. 

Toxic Angina. — This embraces cases due to the abuse of tea, coffee, and 
tobacco. There are three groups of cases of so-called tobacco heart: First, 
the irritable heart of smokers, seen particularly in young lads, in which 
the symptoms are palpitation, irregularity, and rapid action; secondly, 
heart pain of a sharp, shooting character, which may be very severe; and, 
thirdly, attacks of such severity that they deserve the name of angina. 
Huchard remarks that they are usually of the vaso-motor type, accom- 
panied with chilling of the extremities, feeble pulse, and a tendency to syn- 
cope. This author distinguishes between functional tobacco angina, due, 
he thinks, to spasmodic contraction of the coronary arteries, and an organic 
tobacco angina due to a nicotine arterio-sclerosis of these vessels. 

Prognosis. — Cardiac pain without evidence of aTterio-sclerosis or 
valve-disease is not of much moment. True angina is almost invariably 
associated with marked cardio-vascular lesions, in which the prognosis is 
always grave. With judicious treatment the attacks, however, may be 
long deferred, and a few instances recover completely. The prognosis is 
naturally more serious with aortic insufficiency and advanced arterio-scle- 
rosis. Patients who have had well-marked attacks may live for many years, 
but much depends upon the care with which they regulate their daily life. 

Treatment. — Patients subject to this affection should live a quiet 
life, avoiding particularly excitement and sudden muscular exertion. Dur- 
ing the attack nitrite of amyl should be inhaled, as advised by Lauder 
Brunton. Prom 2 to 5 drops may be placed upon cotton-wool in a 
tumbler or upon the handkerchief. This is frequently of great service in 
the attack, relieving the agonizing pain and distress. Subjects of the dis- 



CONGENITAL AFFECTIONS OF THE HEART. 765 

ease should carry the perles of the nitrite of amyl with them, and use them 
on the first indication of an attack. In some instances the nitrite of amyl 
is quite powerless, though given freely. If within a minute or two relief is 
not obtained in this way, chloroform should at once be given. A few in- 
halations act promptly and give great relief. Should the pains continue, 
a hypodermic of morphia may be administered. In severe and repeated 
paroxysms a patient may display remarkable resistance to the action of 
this drug. 

In the intervals, nitroglycerin may be given in full doses, as recom- 
mended by Murrell, or the nitrite of sodium (Matthew Hay). The nitro- 
glycerin should be used for a long time and in increasing doses, beginning 
with 1 minim three times a day of the 1-per-cent solution, and increas- 
ing the dose 1 minim every five or six days until the patient complains 
of flushing or headache. The fluid extract of English hawthorn — crategus 
oxyacantha — has been strongly recommended by Jennings, Clements, and 
others. 

Huchard recommends the iodides, believing that their prolonged use 
influences the arterio-sclerosis. Twenty grains three times a day may be 
given for several years, omitting the medicine for about ten days in each 
month. In some instances this treatment is certainly beneficial. Two 
men, both with arterio-sclerosis, ringing, accentuated aortic sound, and 
attacks of true angina, have under its use remained practically free from 
attacks — one case for nearly three, and the other for fully eight years. 
This treatment is, however, not always satisfactory, and I have had several 
cases in which the condition has not been at all relieved by it. 

For the pseudo-angina, the treatment must be directed to the general 
nervous condition. Electricity is sometimes very beneficial, particularly 
the Franklinic form. 



VI. CONGENITAL AFFECTIONS OF THE HEART. 

These have only a limited clinical interest, as in a large proportion of 
the cases the anomaly is not compatible with life, and in others nothing 
can be done to remedy the defect oi even to relieve the symptoms. 

The congenital affections result from interruption of the normal course 
of development or from inflammatory processes — endocarditis; sometimes 
from a combination of both. 

(a) Of general anomalies of development the following conditions may 
be mentioned: Acardia, absence of the heart, which has been met with 
in the monstrosity known by the same name; double heart, which has occa- 
sionally been found in extreme grades of foetal deformity; dextrocardia, 
in which the heart is on the right side, either alone or as part of a general 
transposition of the viscera; ectopia cordis, a condition associated with 
fission of the chest wall and of the abdomen. The heart may be situated 
in the cervical, pectoral, or abdominal regions. Except in the abdominal 
variety the condition is very rarely compatible with extra-uterine life. 
Occasionally, as in a case reported by Holt, the child lives for some months, 



7CG DISEASES OF THE CIRCULATORY SYSTEM. 

and the heart may be seen and felt beating beneath the skin in the epi- 
gastric region. This infant was five months old at the date of examina- 
tion. 

(b) Anomalies of the Cardiac Septa. — The septa of both auricles and 
ventricles may be defective, in which case the heart consists of but two 
chambers, the cor biloculare or reptilian heart. In the septum of the auri- 
cles there is a very common defect, owing to the fact that the membrane 
closing the foramen ovale has failed at one point to become attached to the 
ring, and leaves a valvular slit which may be large enough to admit the 
handle of a scalpel. Neither this nor the small cribriform perforations of 
the membrane are of any significance. 

The foramen ovale may be patent without a trace of membrane closing 
it. In some instances this exists with other serious defects, such as steno- 
sis of the pulmonary artery, or imperfection of the ventricular septum. 
In others the patent foramen ovale is the only anomaly, and in many in- 
stances it does not appear to have caused any embarrassment, as the con- 
dition has been found in persons who have died of various affections. The 
ventricular septum may be absent, the condition known as trilocular heart. 
Much more frequently there is a small defect in the upper portion of the 
septum, either in the situation of the membranous portion known as the 
" undefended space " or in the region situated just anterior to this. The 
anomaly is very frequently associated with narrowing of the pulmonary 
orifice or of the conus arteriosus of the right ventricle. 

(c) Anomalies and Lesions of the Valves. — Numerical anomalies of the 
valves are not uncommon. The semilunar segments at the arterial orifices 
are not infrequently increased or diminished in number. Supernumerary 
segments are more frequent in the pulmonary artery than in the aorta. 
Four, or sometimes five, valves have been found. TJie segments may be of 
equal size, but, as a rule, the supernumerary valve is small. 

Instead of three there may be only two semilunar valves, or, as it is 
termed, the bicuspid condition. In my experience, this is most frequent 
in the aortic valve. Of 21 instances only 2 occurred at the pulmonary 
orifice. Two of the valves have united, and from the ventricular face 
show either no trace of division or else a slight depression indicating where 
the union had occurred. From the aortic side there is usually to be seen 
some trace of division into two sinuses of Valsalva. There has been a dis- 
cussion as to the origin of this condition, whether it is really an anomaly 
or whether it is not due to endocarditis, foetal or post-natal. The com- 
bined segment is usually thickened, but the fact that this anomaly is met 
with in the foetus without a trace of sclerosis or endocarditis shows that it 
may, in some cases at least, result from a developmental error. 

Clinically this is a very important congenital defect, owing to the 
liability of the combined valve to sclerotic changes. Except two foetal 
specimens all of my cases showed thickening and deformity, and in 15 
of those which I have reported death resulted directly or indirectly from 
the lesion. 

The little fenestrations at the margins of the sigmoid valves have no 
significance; they occur in a considerable proportion of all bodies. 



CONGENITAL AFFECTIONS OF THE HEART. 



767 



Anomalies of the auriculo-ventricular valves are not often met with. 

Foetal endocarditis may occur either at the arterial or auriculo-ven- 
tricular orifices. It is nearly always of the chronic or sclerotic variety. 
Very rarely indeed is it of the warty or verrncose form. There are little 
nodular bodies, sometimes six or eight in number, on the mitral and tri- 
cuspid segments — the nodules of Albini — which represent the remains of 
fcetal structures, and must not be mistaken for endocardial outgrowths. 
The little rounded, bead-like haemorrhages of a deep purple color, which 
are very common on the heart valves of children, are also not to be mis- 
taken for the products of endocarditis. In fcetal endocarditis the segments 
are usually thickened at the edges, shrunken, and smooth. In the mitral 
and tricuspid valves the cusps are found united and the chordae tendineae 
are thickened and shortened. In the semilunar valves all trace of the 
segments has disappeared, leaving a stiff membranous diaphragm per- 
forated by an oval or rounded orifice. It is sometimes very difficult to say 
whether this condition has resulted from fcetal endocarditis or whether it 
is an error in development. In very many instances the processes are 
combined; an anomalous valve becomes the seat of chronic sclerotic 
changes, and, according to Eauchfuss, endocarditis is more common on 
the right side of the heart only because the valves are here most often the 
seat of developmental errors. 

Lesions at the Pulmonary Orifice. — Stenosis of this orifice is one of the 
commonest and most important of congenital heart affections. A slow 
endocarditis causes gradual union of the segments and narrowing of the 
orifice to such a degree that it only admits the smallest-sized probe. In 
some of the cases the smooth membranous condition of the combined seg- 
ments is such that it would appear to be the result of faulty development. 
In some instances vegetations develop. The condition is compatible with 
life for many years, and in a considerable proportion of the cases of heart- 
disease above the tenth year this lesion is present. With it there may be 
defect of the ventricular septum. Pulmonary tuberculosis is a very common 
cause of death. Obliteration or atresia of the pulmonary orifice is less fre- 
quent but a more serious condition than stenosis. It is associated with de- 
fect of the ventricular septum or patency of the foramen ovale and per- 
sistence of the ductus arteriosus with hypertrophy of the right heart. Ste- 
nosis of the conus arteriosus of the right ventricle exists in a considerable 
proportion of the cases of obstruction at the pulmonary orifice. At the out- 
set a developmental error, it may be combined with sclerotic changes. The 
ventricular septum is imperfect, the foramen ovale is usually open, and the 
ductus arteriosus patent. These three lesions at the pulmonary orifice 
constitute the most important group of all congenital cardiac 1 affections. 
Of 181 inBtances of various congenital anomalies collected by Peacock 119 
cases came under this category, and, according to this author, in 8(i per 
cent of the patients living beyond the twelfth year the lesion is at this 
orifice. 

Congenital lesions of the aortic orifice are not very frequent. Eauchfuss 
has collected 24 cases of stenosis and atresia; stenosis of the left conus 
arteriosus may also occur, a condition which is not incompatible with pro- 
4b 



768 



DISEASES OF THE CIRCULATORY SYSTEM. 



longed life. Ten of the 16 eases tabulated by Dilg were over thirty years 
of age. 

Transposition of the large arterial trunks is a not uncommon anomaly. 
There may be neither hypertrophy, cyanosis, nor heart murmur. 

Symptoms of Congenital Heart-disease. — Cyanosis occurs in 
over 90 per cent of the cases, and forms so distinctive a feature that the 
terms " blue disease " and " morbus casruleus " are practically synonyms 
for congenital heart-disease. The lividity in a majority of cases appears 
early, within the first week of life, and may be general or confined to the 
lips, nose, and ears, and to the fingers and toes. In some instances there 
is in addition a general dusky suffusion, and in the most extreme grades 
the skin is almost purple. It may vary a good deal and may only be in- 
tense on exertion. The external temperature is low. Dyspnoea on exertion 
and cough are common symptoms. A great increase in the number of the 
red corpuscles has been noted by Gibson and by Vaquez. In a case of Gib- 
son's there were above eight millions of red blood-corpuscles to the cubic 
millimetre. The children rarely thrive, and often display a lethargy of both 
mind and body. The fingers and toes are clubbed to a degree rarely met 
with in any other affection. The cause of the cyanosis has been much dis- 
cussed. Morgagni referred it to the general congestion of the venous sys- 
tem due to obstruction, and this view was supported in a paper, one of the 
ablest that has been written on the subject, by Moreton Stille. Morrison's 
recent analysis of 75 cases of congenital heart-disease shows that closure 
of the pulmonary orifice and patency of the foramen ovale and the ven- 
tricular septum are the lesions most frequently associated with cyanosis, 
and he concludes that the deficient aeration of the blood owing to dimin- 
ished lung function is the most important factor. Another view, often 
attributed erroneously to William Hunter, was that the discoloration was 
due to the admixture in the heart of venous and arterial blood; but lesions 
may exist which permit of very free mixture without producing cyanosis. 
The question of the cause of cyanosis really can not be considered as set- 
tled. Yariot has recently made the suggestion that the cause is not en- 
tirely cardiac, but is associated with disturbance throughout the whole 
circulatory system, and particularly a vaso-motor paresis and malaeration 
of the red blood-corpuscles. 

Diagnosis. — In the case of children, cyanosis, with or without en- 
largement of the heart, and the existence of a murmur are sufficient, as a 
rule, to determine the presence of a congenital heart-lesion. The cyanosis 
gives us no clew to the precise nature of the trouble, as it is a symptom 
common to many lesions and it may be absent in certain conditions. The 
murmur is usually systolic in character. It is, however, not always pres- 
ent, and there are instances on record of complicated congenital lesions m 
which the examination showed normal heart-sounds. In two or three in- 
stances foetal endocarditis has been diagnosed in gravida by the presence 
of a rough systolic murmur, arid the condition has been corroborated sub- 
sequent to the birth of the child. Hypertrophy is present in a majority of 
the cases of congenital defect. The fatal event may be caused by abscess 
of the brain. It is impossible in a work of this sort to enter upon elabo- 



CONGENITAL AFFECTIONS OF THE HEART. 769 

« 

rate details in differential diagnosis between the various congenital heart- 
lesions. I here abstract the conclusions of Hochsinger: 

" (1) In childhood, loud, rough, musical heart-murmurs, with normal 
or only slight increase in the heart-dulness, occur only in congenital heart- 
disease. The acquired endocardial defects with loud heart-murmurs in 
young children are almost always associated with great increase in the 
heart-dulness. In the transposition of the large arterial trunks there may 
be no cyanosis, no heart-murmur, and an absence of hypertrophy. 

" (2) In young children heart-murmurs with great increase in the car- 
diac dulness and feeble apex beat suggest congenital changes. The in- 
creased dulness is chiefly of the right heart, whereas the left is only slightly 
altered. On the other hand, in the acquired endocarditis in children, the 
left heart is chiefly affected and the apex beat is visible; the dilatation of 
the right heart comes late and does not materially change the increased 
strength of the apex beat. 

" (3) The entire absence of murmurs at the apex, with their evident 
presence in the region of the auricles and over the pulmonary orifice, is al- 
ways an important element in differential diagnosis, and- points rather to 
septum defect or pulmonary stenosis than to endocarditis. 

" (4) An abnormally weak second pulmonic sound associated with a 
distinct systolic murmur is a symptom which in early childhood is only to 
be explained by the assumption of a congenital pulmonary stenosis, and 
possesses therefore an importance from a point of differential diagnosis 
which is not to be underestimated. 

" (5) Absence of a palpable thrill, despite loud murmurs which are 
heard over the whole precordial region, is rare except with congenital de- 
fects in the septum, and it speaks therefore against an acquired cardiac 
affection. 

" (6) Loud, especially vibratory, systolic murmurs, with the point of 
maximum intensity over the upper third of the sternum, associated with 
a lack of marked symptoms of hypertrophy of the left ventricle, are very 
important for the diagnosis of a persistence of the ductus Botalli, and can- 
not be explained by the assumption of an endocarditis of the aortic valve." 

Escherich suggests that the systolic basic murmur heard sometimes in 
the newborn, particularly if premature, may originate in the ductus Botalli 
before its closure. 

Treatment. — The child should be warmly clad and guarded from all 
circumstances liable to excite bronchitis. In the attacks of urgent dysp- 
noea with lividity blood should be freely let. Saline cathartics are also 
useful. Digitalis must be used with care; it is sometimes beneficial in the 
later stages. When the compensation fails, the indications for treatment 
are those of valvular disease in adults. 



770 



DISEASES OF THE CIRCULATORY SYSTEM. 



III. DISEASES OE THE AKTERIES. 
I. DEGENERATIONS. 

Fatty degeneration of the intima is extremely common, and is seen in 
the form of yellowish-white spots in the aorta and larger vessels. Calcifica- 
tion of the arterial wall follows fatty degeneration and sclerosis, and is asso- 
ciated with atheromatous changes. It occurs in the intima and the media. 
In the latter it produces what is sometimes known as annular calcification, 
which occurs particularly in the middle coat of medium-sized vessels and 
may convert them into firm tubes. 

Hyaline degeneration may attack either the larger or the smaller vessels. 
In the former the intima is converted into a smooth, homogeneous sub- 
stance; this is commonly an initial stage of arteriosclerosis; here it is a 
transformation of the endothelial lining. Of the smaller arteries and capil- 
laries hyaline metamorphosis is oftenest seen in the glomeruli of the kidneys. 
It is not to be confounded with the amyloid change which is prone to 
occur in the same situation. The condition is variously regarded as due 
to coagulation of an albuminous fluid and hyaline metamorphosis 
,iOf leucocytes or of fibrin. This substance reacts like the last with Weigert's 
fibrin stain. 



II. ARTERIOSCLEROSIS (Arterio-capittary Fibrosis). 

The conception of arterio-sclerosis as an independent affection — a gen- 
eral disease of the vascular system — is due to Gull and Sutton. 

Definition. — A condition of thickening, diffuse or circumscribed, be- 
ginning in the intima, consequent upon primary changes in the media and 
adventitia, but which later involves the other coats. The process leads, in 
the larger arteries, to what is known as atheroma antl to endarteritis defor- 
mans, and seriously interferes with the normal functions of various organs. 

Etiology. — (1) As an involution process arterio-sclerosis is an accom- 
paniment of old age, and is the expression of the natural wear and tear to 
which the tubes are subjected. Longevity is a vascular question, which has 
been well expressed in the axiom that " a man is only as old as his arte- 
ries." To a majority of men death comes primarily or secondarily through 
this portal. The onset of what may be called physiological arterio-sclerosis 
depends, in the first place, upon the quality of arterial tissue (vital rub- 
ber) which the individual has inherited, and secondly upon the amount of 
wear and tear to which he has subjected it. That the former plays a 
most important role is shown in the cases in which arterio-sclerosis sets in 
early in life in individuals in whom none of the recognized etiological fac- 
tors can be found. Thus, for instance, a man of twenty-eight or twenty- 
nine may have the arteries of a man of sixty, and a man of forty may pre- 
sent vessels as much degenerated as they should be at eighty. Entire fami- 
lies sometimes show this tendency to early arterio-sclerosis — a tendency 



ARTERIO-SCLEROSIS. 



which cannot be explained in any other way than that in the make-up of the 
machine bad material was used for the tubing. 

More commonly the arterio-sclerosis results from the bad use of good 
vessels, and among the circumstances which tend to produce this condi- 
tion are the following: 

(2) Chronic Intoxications. — Alcohol, lead, gout, and syphilis play an 
important role in the causation of arterio-sclerosis, although the precise 
mode of their action is not yet very clear. They may act, as Traube sug- 
gests, by increasing the peripheral resistance in the smaller vessels and in 
this way raising the blood tension, or possibly, as Bright taught, they alter 
the quality of the blood and render more difficult its passage through the 
capillaries. 

The poisons of syphilis and of gout, as well as of many of the acute in- 
fections, may produce degenerative changes in the media and adventitia. 

(3) Overeating. — I am more and more impressed with the part played by 
overeating in inducing arterio-sclerosis. There are many cases in which 
there is no other factor. The high pressure at which many men now live 
must also be taken into account. George Cheyne's advice, which I quote 
at page 470, was never more needed than by the present generation. 

(4) Overwork of the muscles, which acts by increasing the peripheral re- 
sistance and by raising the blood-pressure. 

(5) Renal Disease. — The relation between the arterial and kidney lesions 
has been much discussed, some regarding the arterial degeneration as sec- 
ondary, others as primary. There are two groups of cases, one in which the 
arterio-sclerosis is the first change, and the other in which it is secondary 
to a primary affection of the kidneys. The former occurs, I believe, with 
much greater frequency than has been supposed. 

Morbid Anatomy. — Thoma divides the cases into primary arterio- 
sclerosis, in which there are local changes in the arteries leading to dilata- 
tion and a compensatory increase of the connective tissue of the intima; 
secondary arterio-sclerosis, due to changes in the arteries which follow in- 
creased resistance to the blood-flow in the peripheral vessels. This in- 
creased tension leads to dilatation and to slowing of the blood-stream and a 
secondary compensatory development of the intima. 

In a study of 41 autopsies upon arteriosclerotic cases from my wards, 
Councilman follows the useful division into nodular, senile, and diffuse 
forms. 

(a) Nodular Form. — In the circumscribed or nodular variety the ma- 
croscopic changes are very characteristic. The aorta presents, in the early 
stages, from the ring to bifurcation, numerous flat projections, yellowish 
or yellowish-white in color, hemispherical in outline, and situated particu- 
larly about the orifices of the branches. In the early stage these patches 
are scattered and do not involve the entire intima. In more advanced 
grades the patches undergo atheromatous changes. The material constitut-* 
ing the button undergoes softening and breaks up into granular material, 
consisting of molecular debris — the so-called atheromatous abscess.- 

In the circumscribed or nodular arterio-sclerosis the primary alteration 
consists in a degeneration or a local infiltration in the media and adven- 
titia, chiefly about the vasa vasorum. The affection is really a mesarteritis 



772 DISEASES OF THE CIRCULATORY SYSTEM. 



and a periarteritis. These changes lead to the weakening of the wall in 
the affected area, at which spot the proliferative changes commence in the 
intima, particularly in the subendothelial structures, with gradual thick- 
ening and the formation of an atheromatous "button or a patch of nodular 
arterio-sclerosis. The researches of Thoma have shown that this is really 
a compensatory process, and that before its degeneration the nodular but- 
ton, which post mortem projects beyond the lumen, during life fills up and 
obliterates what would otherwise be a depression of the wall in consequence 
of the weakening of the media. A similar process goes on in the smaller 
vessels, and in any one of the smaller branches it can be readily seen on sec- 
tion that each patch of endarteritis corresponds to a defect in the media 
and often to changes in the adventitia. The condition is one which may 
lead to rapid dilatation or to the production of an aneurism, particularly in 
the early stage, before the weakened spot is thickened and strengthened by 
the intimal changes. 

(b) Senile Arterio-sclerosis. — The larger arteries are dilated and tortu- 
ous, the walls thin but stiff, and often converted into rigid tubes. The 
subendothelial tissue undergoes degeneration and in spots breaks down, 
forming the so-called atheromatous abscess, the contents of which con- 
sist of a molecular debris. They may open into the lumen, when they are 
known as atheromatous ulcers. The greater portion of the intima may 
be occupied by rough calcareous plates, with here and there fissures and 
losses of substance, upon which not infrequently white thrombi are de- 
posited. Microscopically there is extreme degeneration of the coats, par- 
ticularly of the media. Senile atrophy of the liver and kidneys usually ac- 
companies these changes. Senile changes are common in other organs. 
The heart may be small and is not necessarily hypertrophied. In 7 of 14 
cases of Councilman's series there was no enlargement. Brown atrophy is 
common. 

(c) Diffuse Arterio-sclerosis. — The process is widespread throughout the 
aorta and its branches, in the former usually, but not necessarily; associated 
with the nodular form. The subjects of this variety are usually middle- 
aged men, but it may occur early. Of the 27 in Councilman's series be- 
longing to this group the majority were between the ages of forty and fifty- 
five. The youngest was a negro of twenty-three and the oldest a man of 
sixty. The affection is very prevalent among negroes; less than 50 per cent 
were in whites, whereas the ratio of colored to white patients in the wards 
is one to seven. The affection is met with in strongly built, muscular men 
and, as Councilman remarks, they rarely present on the autopsy table signs 
of general anasarca or, if oedema exists, it has come on during the last few 
days of life. The aorta and its branches are more or less dilated, the 
branches sometimes more than the trunk. The intima may be smooth and 
show very slight changes to the naked eye; more commonly there are scat- 
tered elevated areas of an opaque white color, some of which may have un- 
dergone atheromatous changes as in the senile form. 

Microscopically in the several forms the media shows necrotic and hya- 
line changes, involving in the larger arteries both muscular and elastic ele- 
ments, and the intima presents a great increase in the subendothelial con- 



ARTERIO-SCLEROSIS. 



773 



nective tissue, which is particularly marked opposite areas of advanced 
degeneration in the media. The small arteries — those in the kidneys, for 
example — show " a thickening of the wall, due to the formation of a homo- 
geneous hyaline tissue within the muscular coat. This tissue contains but 
few cells, is faintly striated, and stains a light brown in the osmic acid used 
in the hardening solution. In many of the smallest vessels nothing can be 
seen of the elastic lamina, in others only fragments can be made out, in 
others it is preserved. . . . The muscular fibres of the media show marked 
atrophic changes. Fatty degeneration of the cells can be made out both in 
fresh sections and after hardening in Flemming's solution. The nuclei are 
thin and atrophic and vacuoles are sometimes seen in them. In some ar- 
teries the muscle-fibres have almost disappeared and the media is changed 
into a homogeneous tissue, similar to that in the thickened intima " (Coun- 
cilman). The degeneration of the media is most marked in the smaller 
arteries. The capillaries are thickened, particularly those of the glomeruli 
of the kidneys, which are often obliterated and involved in extensive hya- 
line degeneration. 

It is in this group of cases that the heart shows the most important 
changes. The average weight in the cases referred to was over 450 grammes, 
and there were two cases in which without valvular disease the weight was 
over 800 grammes. Fibrous myocarditis is often present, particularly when 
the coronary arteries are involved. The semilunar valves are sometimes 
opaque and sclerotic, and may be incompetent. The kidneys may show 
extensive sclerosis, but in many cases the changes are so slight that macro- 
scopically they might be overlooked. They may be increased in size. The 
capsule is usually adherent, the surface a little rough, and very often pre- 
sents atrophic areas at a lower level, of a deep-red color. Increased consist- 
ence is always present. 

Sclerosis of the pulmonary artery is met with in all conditions which 
for a long time increase the tension in the lesser circulation, particularly 
in mitral valve disease and in emphysema. Sometimes the sclerosis reaches 
a high grade and is accompanied with aneurismal dilatation of the primary 
and secondary branches, more rarely with insufficiency of the pulmonary 
valve. In a remarkable case of a young man of twenty-four, reported by 
Eomberg from Curschmann's clinic, the pulmonary arteries were involved 
in most extensive arterio-sclerosis; the main branches were dilated, and the 
smaller branches were the seat of the most extreme sclerotic changes. On 
the other hand, the aorta and its branches were normal. The heart was 
greatly hypertrophied, and the clinical symptoms were those of a congeni- 
tal heart affection. In many cases of arterio-sclerosis the condition is not 
confined to the arteries, but extends not only to the capillaries but also to 
the veins, and may properly be termed an angio-sclerosis. 

Sclerosis of the veins — phlebo-sclerosis — is not at all an uncommon ac- 
companiment of arterio-sclerosis, and is a condition to which of late a good 
deal of attention has been paid. It is seen in conditions of heightened 
blood-pressure, as in the portal system in cirrhosis of the liver and in the 
pulmonary veins in mitral stenosis. The affected vessels are usually dilated, 
and the intima shows, as in the arteries, a compensatory thickening, which 



DISEASES OF THE CIRCULATORY SYSTEM. 



is particularly marked in those regions in which the media is thinned. 
The new-formed tissue in the endophlebitis may undergo hyaline degenera- 
tion, and is sometimes extensively calcified. In a case of fibroid oblitera- 
tion of the portal vein of long standing, I found the intima of the greatly 
dilated gastric, splenic, and mesenteric veins extensively calcified. Without 
existing arterio-sclerosis the peripheral veins may be sclerotic, usually in 
conditions of debility, but occasionally in young persons. 

Symptoms. — Increased Tension. — The pressure with which the blood 
flows in the arteries depends upon the degree of peripheral resistance and 
the force of the ventricular contraction. A high-tension pulse may exist 
with very little arterio-sclerosis; but, as a rule, when the condition has been 
persistent, the sclerosis and high tension are found together. The pulse 
wave is slow in its ascent, enduring, subsides slowly, and in the intervals 
between the beats the vessel remains full and firm. It may be very difficult 
to obliterate the pulse, and the firmest pressure on the radial or the tem- 
poral artery may not be sufficient to annihilate the pulse wave beyond the 
point of pressure. This is not always a sign of high tension. The anas- 
tomotic or recurrent pulse may be felt even when the tension is low, as in 
the early stage of typhoid fever. Pressure on the ulnar artery at once ob- 
literates it.* The sphygmographic tracing shows a sloping, short up-stroke, 
no percussion wave, and a slow, gradual descent, in which the dicrotic wave 
is very slightly marked. It may be difficult to estimate how much of the 
hardness and firmness is due to the tension of the blood within the vessel, 
and how much to the thickening of the wall. But if, for example, when 
the radial is compressed with the index-finger the artery can be felt beyond 
the point of compression, its walls are sclerosed. 

Hypertrophy of the Heart. — In consequence of the peripheral resistance 
and increased work the left ventricle increases in size, and some of the 
purest examples of simple hypertrophy occur in this condition. The cham- 
ber may be little, if at all, dilated. The apex beat is dislocated in advanced 
cases an inch or more beyond the nipple line. The impulse is heaving and 
forcible. The aortic second sound is clear, ringing, and accentuated. 

The combination of increased arterial tension, a palpable thickening 
of the arteries, hypertrophy of the left ventricle, and accentuation of the 
aortic second sound are signs pathognomonic of arterio-sclerosis. From 
this period of establishment the course of the disease may be very varied. 
For years the patient may have good health, and be in a condition analo- 
gous to that of a person with a well-compensated valvular lesion. There 
may be no renal symptoms, or there may be the passage of a larger amount 
of urine than normal, with transient albuminuria, and now and then 
hyaline tube-casts. The subsequent history is extraordinarily diverse, de- 
pending upon the vascular territory in which the sclerosis is most advanced, 
or upon the accidents which are so liable to happen, and the symptoms may 
be cardiac, cerebral, renal, etc. 

(1) Cardiac. — The involvement of the coronary arteries may lead to 
the various symptoms already referred to under that section — thrombosis 



* The student is referred to E wart's and to Broadbent's manuals on the pulse. 



ARTERIOSCLEROSIS. 



with sudden death, fibroid degeneration of the heart, aneurism of the heart, 
rupture, and angina pectoris. Angina pectoris is not uncommon, and in 
the true variety is almost always associated with arterio-sclerosis. A sec- 
ond important group of cardiac symptoms results from the dilatation which 
ultimately may follow the hypertrophy. The patient then presents all the 
symptoms of cardiac insufficiency — dyspnoea, scanty urine, and very often 
serous effusions. If the case has come under observation for the first time 
the clinical picture is that of chronic valvular disease, and the existence of 
a loud blowing murmur at the apex may throw the practitioner off his 
guard. Many cases terminate in this way. 

(2) The cerebral symptoms of arterio-sclerosis are varied and important, 
and embrace those af many degenerative diseases, acute and chronic (which 
follow sclerosis of the smaller branches), and cerebral haemorrhage. 

Transient hemiplegia, monoplegia, or aphasia may occur in advanced 
arterio-sclerosis. Eecovery may be perfect. It is difficult to say upon 
what these attacks depend. Spasm of the arteries has been suggested, but 
the condition of the smallest arteries is not very favorable to this view. 
Peabody has recently called attention to these cases, which are more com- 
mon than is indicated in the literature. Vertigo occurs frequently, and may 
be either simple, or is associated with slow pulse and syncopal or epilepti- 
form attacks — the Stokes-Adams syndrome. 

(3) Renal symptoms supervene in a large number of the cases. A sclero- 
sis, patchy or diffuse, is present in a majority of the cases at the time of 
autopsy, and the condition is practically that of contracted kidney. It is 
seen in a typical manner in the senile form, and not infrequently develops 
early in life as a direct sequence of the diffuse variety. It is often difficult 
to decide clinically (and the question is one upon which good observers 
might not agree in a given case) whether the arterial or the renal disease 
has been primary. 

(4) Among other events in arterio-sclerosis may be mentioned gangrene 
of the extremities, due either directly to endarteritis or to the dislodgment 
of thrombi. Sudden transient paraplegia may occur, and the remarkable 
condition known as intermittent claudication. 

Treatment. — In the late stages the conditions must be treated as they 
arise in connection with the various viscera. In the early stages, before 
any local symptoms are manifest, the patient should be enjoined to live a 
quiet, well-regulated life, avoiding excesses in food and drink. It is usu- 
ally best to explain frankly the condition of affairs, and so gain his intelli- 
gent co-operation. Special attention should be paid to the state of the 
bowels and urine, and the secretion of the skin should be kepi active by 
daily baths. Alcohol in all forms should be prohibited, and the food should 
be restricted to plain, wholesome articles. The use of mineral wafers or a * 
residence every year at one of the mineral springs is usually serviceable. 
If there has been ;i syphilitic history an occasional course of iodide of po- 
tassium is indicated, and whenever the pulse tension is high nitroglycerin 
may be used. 

In cases which come under observation for the first time with dyspnoea, 
slight lividity, and signs of cardiac insufficiency, venesection is indicated. 



776 



DISEASES OF THE CIRCULATORY SYSTEM. 



In some instances, with very high tension, striking relief is afforded by the 
abstraction of 20 ounces of blood. 



III. ANEURISM. 

The following forms of aneurism are usually recognized: 

(a) The true, in which the sac is formed of one or more of the arterial 
coats. This may be fusiform, cylindrical, or cirsoid (in which the dilatation 
is in an artery and its branches), or it may be circumscribed or sacculated. 
Aneurisms are usually fusiform, resulting from uniform dilatation of the 
vessel, or saccular. 

(b) The false aneurism, in which there is rupture of all the coats, and 
the blood is free (or circumscribed) in the tissues. 

(c) The dissecting aneurism, which results from injury or laceration of 
the internal coat. The blood dissects betwen the layers; hence the name, 
dissecting aneurism. This occurs usually in the aorta, persisting for years^ 

(d) Arterio-venous aneurism results when a communication is established 
between an artery and a vein. A sac may intervene, in which case we have 
what is called a varicose aneurism; but in many cases the communication is 
direct and the chief change is in the vein, which is dilated, tortuous, and 
pulsating, the condition being termed an aneurismal varix. 

Etiology and Pathology. — Aneurisms arise: (a) By the gradual 
diffuse distention of the arterial coats, which have been weakened by arterio- 
sclerosis, particularly in its early stages, before compensatory endarteritis 
develops. The arch of the aorta is often dilated in this way so as to form 
an irregular aneurism. 

(b) In consequence of circumscribed loss of resisting power in the media 
and adventitia, and often from a laceration of the media. This is the 
most common cause of sacculated aneurism. The laceration is frequently 
found in the ascending portion of the arch and occurs early in the process 
of arterio-sclerosis, before the compensatory thickening has taken place. 
Occasionally one meets with remarkable specimens illustrating the impor- 
tant part played by this process. The intima may also be torn. In a case 
of Daland's there was just above the aortic valves an old transverse tear 
of the intima, extending almost the entire circumference of the vessel. 
Sclerosis of the media and adventitia had taken place and the process was 
evidently of some standing. An inch or more above it was a fresh trans- 
verse rent which had produced a dissecting aneurism. These arterioscle- 
rotic aneurisms, as they are called, are found also in the smaller vessels. 

(c) Embolic Aneurism. — When an embolus has lodged in a vessel and 
permanently plugged it, aneurismal dilatation may follow on the proximal 
side. The embolus itself may, if a calcified fragment from a valve, lacer- 
ate the wall, or if infected may produce inflammation and softening. 

(d) Mycotic Aneurism. — The importance of this form has been specially 
considered by Eppinger in his exhaustive monograph. The occurrence of 
multiple aneurisms in malignant endocarditis has been observed by several 
writers. Probably the first ease in which the mycotic nature was recog- 



ANEURISM. 



777 



nized was one which occurred at the Montreal General Hospital and is re- 
ported in full in my lectures on malignant endocarditis. In addition to the 
ulceration of the valves there were four aneurisms of the arch, of which 
one was large and saccular, and three were not bigger than cherries. An ex- 
tensive growth of micrococci was present. 

A form of parasitic aneurism which occurs with great frequency in the 
mesenteric arteries of the horse is due to the development of the strongylus 
armatus. 

Thoma has described a " traction " aneurism of the concavity of the 
arch at the point of insertion of the remnant of the ductus Botalli (Vir- 
chow's Archiv, Bd. 122). 

And, lastly, there are cases in which without any definite cause there 
is a tendency to the development of aneurisms in various parts of the 
body. A remarkable instance of it in our profession was afforded by the 
brilliant Thomas King Chambers, who first had an aneurism in the left 
popliteal artery, eleven years subsequently an aneurism in the right 
leg which was cured by pressure, and finally aneurisms of the carotid 
arteries. 

Incidence of Aneurism. — At St. Bartholomew's Hospital during thirty 
years there were 631 cases of aneurism. In 468 the disease affected the 
aorta, in 80 the popliteal, in 21 the femoral, in 14 the subclavian, in 8 the 
carotid, in 6 the external iliac artery (Oswald A. Browne). 

Aneueism of the Thoeacic Aoeta. 

The causes which favor the development of arterio-sclerosis prevail in 
aortic aneurism, particularly alcohol, syphilis, and overwork. The great- 
est danger probably is in strong muscular men with commencing degen- 
erative processes in the arteries (a consequence of syphilis or alcohol or a 
result of hereditary weakness of the arterial tissues), who during a sudden 
muscular exertion are liable to lacerate the media, the intima not yet being 
strengthened by compensatory thickening over a spot of mesarteritis. Aneu- 
risms of the thoracic aorta vary greatly in size and shape. A majority of 
them are saccular. They may be small and, situated just above the aortic 
ring. Others form large tumors which project externally and occupy a 
large portion of the upper thorax. Small sacs from the descending por- 
tion of the arch may compress the trachea or the bronchi. In the tho- 
racic portion the sac may erode the vertebras or grow into the pleural cavity 
and compress the lung. In some instances it grows through the ribs and 
appears in the back. 

Symptoms. — The chief influence of an aneurism is manifested in 
what are known as pressure effects. In the absence of these the aneurisms 
attain a large size without producing symptoms or seriously interfering 
with the circulation. Indeed, a useful clinical subdivision as given by 
Bramwcll is into three groups — aneurisms which arc entirely Intent and 
give no physical signs; aneurisms which present signs of intrathoracic 
pressure, although it is difficult or impossible to determine the nature of the 
lesion producing the pressure; and, lastly, aneurisms which produce dis- 



778 



DISEASES OF THE CIRCULATORY SYSTEM. 



tinct tumors with well-marked pressure symptoms and external signs. 
Broadbent makes another useful division into aneurism of symptoms and 
aneurism of physical signs. It is perhaps best to consider aneurisms of the 
aorta according to the situation of the tumor. 

(a) Aneurisms of the Ascending Portion of the Arch. — When just above 
the sinuses of Valsalva they are often small and latent. The first symp- 
tom may be rupture, which usually takes place into the pericardium and 
causes instant death. Above the sinuses, along the convex border of the 
ascending part, aneurism frequently develops, and may grow to a large 
size, either passing out into the right pleura or forward, pointing at the 
second or third interspace, eroding the ribs and sternum, and producing 
large external tumors. In this situation the sac is liable, indeed, to com- 
press the superior vena cava, causing engorgement of the vessels of the 
head and arm, sometimes compressing only the subclavian vein, and caus- 
ing enlargement and oedema of the right arm. Perforation may take place 
into the superior vena cava, of which accident Pepper and Griffith have 
collected 29 cases. In rare instances, when the aneurism springs from the 
concave side of the vessels, the tumor may appear to the left of the sternum. 
Large aneurisms in this situation may cause much dislocation of the 
heart, pushing it down and to the left, and sometimes compressing the 
inferior vena cava, and causing swelling of the feet and ascites. The right 
recurrent laryngeal nerve is often pressed upon by these tumors. The in- 
nominate artery is rarely involved. Death commonly follows from rupture 
into the pericardium, the pleura, or into the superior cava; less commonly 
from rupture externally, sometimes from syncope. 

(b) Aneurisms of the Transverse Arch. — The direction of their growth is 
most commonly backward, but they may grow forward, erode the sternum, 
and produce large tumors. The tumor presents in the middle line and to 
the right of the sternum much more often than to the left, which occurred 
in only 4 of 35 aneurisms in this situation (0. A. Browne). Even when 
small and producing no external tumor they may cause marked pressure 
signs in their growth backward toward the spine, involving the trachea 
and the oesophagus, and giving rise to cough, which is often of a parox- 
ysmal character, and dysphagia. The left recurrent laryngeal is often in- 
volved in its course round the arch. A small aneurism from the lower or 
posterior wall of the arch may compress a bronchus, inducing bronchor- 
rhcea, gradual bronchiectasy, and suppuration in the lung — a process which 
Jby no means infrequently causes death in aneurism, and a condition which 
at the Montreal General Hospital we were in the habit of terming aneu- 
rismal phthisis. Occasionally enormous aneurisms develop in this situa- 
tion, and grow into both pleurae, extending between the manubrium and the 
vertebrae; they may persist for years. The sac may be evident at the sternal 
notch. The innominate arter}^, less commonly the left carotid and sub- 
clavian, may be involved in the sac, and the radial or carotid pulse may be 
absent or retarded. Pressure on the sympathetic may at first cause dilata- 
tion and subsequently contraction of the pupil. Sometimes the thoracic 
duct is compressed. 

The ascending and transverse portions of the arch are not infrequently 



ANEURISM. 



779 



involved together, usually without the branches; the tumor grows upward, 
or upward and to the right. 

(c) Aneurisms of the Descending Portion of the Arch. — The sac projects 
to the left and backward, and often erodes the vertebra? from the third to 
the sixth dorsal, causing great pain and sometimes compression of the spinal 
cord. Dysphagia is common. Pressure on the bronchi may induce bron- 
chiectasy, with retention of secretions, and fever. A tumor may appear 
externally in the region of the scapula, and here attain an enormous size. 
Death not infrequently occurs from rupture into the pleura. 

{d) Aneurisms of the Descending Thoracic Aorta. — The larger number 
occur close to the diaphragm, the sac lying upon or to the left of the bodies 
of the lower dorsal vertebrae, which are often eroded. The sac may reach 
a large size and form a very large tumor in the back. 

Diagnosis and Physical Signs. — Inspection. — A good light is es- 
sential; cases are often overlooked owing to a hasty inspection. In many 
instances it is negative. On either side of the sternum there may be abnor- 
mal pulsation, due to dislocation of the heart, to deformity of the thorax, 
or to retraction of the lung. The aneurismal pulsation is usually above 
the level of the third rib and most commonly to the right of the sternum, 
either in the first or second interspace. It may be only a' diffuse heaving 
impulse without any external tumor. Often the impulse is noticed only 
when the chest is looked at obliquely in a favorable light. When the in- 
nominate is involved the throbbing may pass into the neck or be apparent 
at the sternal notch. Posteriorly, when pulsation occurs, it is most com- 
monly found to the left of the spine. An external tumor is present in 
many cases, projecting either through the upper part of the sternum or to 
the right, sometimes involving the sternum and costal cartilages on both 
sides, forming a swelling the size of a cocoa-nut or even larger. The skin 
is thin, often blood-stained, or it may have ruptured, exposing the laminae 
of the sac. The apex beat may be much dislocated, particularly when the 
sac is large. It is more commonly a dislocation from pressure than from 
enlargement of the heart itself. 

Palpation. — The area and degree of pulsation are best determined by 
palpation. When the aneurism is deep-seated and not apparent externally, 
the bimanual method should be used, one hand upon the spine and the 
other on the sternum. When the sac has perforated the chest wall the 
impulse is, as a rule, forcible, slow, heaving, and expansile. The resistance 
may be very great if there are thick laminae beneath the skin; more rarely 
the sac is soft and fluctuating. The hand upon the sac, or on the region 
in which it is in contact with the chest wall, feels in many cases a diastolic 
shock, often of great intensity, which forms one of the valuable physical 
signs of aneurism. A systolic thrill is sometimes present, not so often in 
saccular aneurisms as in the dilatation of the arch. The pulsation may 
sometimes be felt in the suprasternal notch. 

Percussion. — The small and deep-seated aneurisms are in this respect 
negative. In the larger tumors, as soon as the sac readies the chest wall, 
there is produced an area of abnormal dulness, the position of which de- 
pends upon the part of the aorta affected. Aneurisms of the ascending 



780 



DISEASES OF THE CIRCULATORY SYSTEM. 



arch, grow forward and to the right, producing dulness on one side of the 
manubrium; those from the transverse arch produce dulness in the middle 
line, extending toward the left of the sternum, while aneurisms of the 
descending portion most commonly produce dulness in the left inter- 
scapular and scapular regions. The percussion note is flat and gives a 
feeling of increased resistance. 

Auscultation. — Adventitious sounds are not always to be heard. Even 
in a large sac there may be no murmur. Much depends upon the thick- 
ness of the laminae of fibrin. An important sign, particularly if heard 
over a dull region, is a ringing, accentuated second sound, a phenomenon 
rarely missed in large aneurisms of the aortic arch. A systolic murmur 
may be present; sometimes a double murmur, in which case the diastolic 
bruit is usually due to associated aortic insufficiency. The systolic mur- 
mur alone is of little moment in the diagnosis of an aneurismal sac. With 
the single stethoscope the shock of the impulse with the first sound is 
sometimes very marked. 

Among other physical signs of importance are slowing of the pulse in 
the arteries beyond the aneurism, or in those involved in the sac. There 
may, for instance, be a marked difference between the right and left radial, 
both in volume and time. A physical sign of large thoracic aneurism, 
which I have not seen referred to, is obliteration of the pulse in the ab- 
dominal aorta and its branches. My attention was called to this in a 
patient who was stated to have aortic insufficiency. There was a well- 
marked diastolic murmur, but in the femorals and in the aorta I was 
surprised to find no trace of pulsation, and not the slightest throbbing in 
the abdominal aorta or in the peripheral arteries of the leg. The circula- 
tion was, however, unimpaired in them and there was no dilatation of the 
veins. 'Attracted by this, I then made a careful examination of the pa- 
tient's back, when the circumstance was discovered, which neither the 
patient himself nor any of his physicians had noticed, that he had a very 
large area of pulsation in the left scapular region. The sac probably was 
large enough to act as a reservoir annihilating the ventricular systole, and 
converting the intermittent into a continuous stream. 

The tracheal tugging, a valuable sign in deep-seated aneurisms, was 
described by Surgeon-Major Oliver, and was specially studied by my col- 
leagues Eoss and MacDonnell * at the Montreal General Hospital. Oliver 
gives the following directions: "Place the patient in the erect position, 
and direct him to close his mouth and elevate his chin to almost the full 
extent; then grasp the cricoid cartilage between the finger and thumb, 
and use steady and gentle upward pressure on it, when, if dilatation or 
aneurism exists, the pulsation of the aorta will be distinctly felt trans- 
mitted through the trachea to the hand/' On several occasions I have 
known this to be a sign of great value in the diagnosis of deep-seated aneu- 
risms. I have never felt it in tumors, or in the extreme dynamic dilatation 
of aortic insufficiency. It may be visible in the thyroid cartilage. 

Occasionally a systolic murmur may be heard in the trachea, as pointed 



* London Lancet, 1891. 



ANEURISM. 



781 



out by David Drummond, or even at the patient's mouth, when opened. 
This is either the sound conveyed from the sac, or is produced by the air 
as it is driven out of the wind-pipe during the systole. 

An important but variable feature in thoracic aneurism is pain, which 
is particularly marked in deep-seated tumors. It is usually paroxysmal, 
sharp, and lancinating, often very severe when the tumor is eroding the 
vertebrse, or perforating the chest wall. In the latter case, after perfora- 
tion the pain may cease. Anginal attacks are not uncommon, particularly 
in aneurisms at the root of the aorta. Frequently the pain radiates down 
the left arm or up the neck; sometimes along the upper intercostal nerves. 
Cough results either from the direct pressure on the wind-pipe, or is as- 
sociated with bronchitis. The expectoration in these instances is abundant, 
thin, and watery; subsequently it becomes thick and turbid. Paroxysmal 
cough of a peculiar brazen, ringing character is a characteristic symptom 
in some cases, particularly when there is pressure on the recurrent laryn- 
geal nerves, or the cough may have a peculiar wheezy quality — the " goose 
cough." 

Dyspnoea, which is common in cases of aneurism of the transverse por- 
tion, is not necessarily associated with pressure on the recurrent laryn- 
geal nerves, but may be due directly to compression of the trachea or the 
left bronchus. It may occur with marked stridor. Loss of voice and 
hoarseness are consequences of pressure on the recurrent laryngeal, usually 
the left, inducing either a spasm in the muscles of the left vocal cord or 
paralysis. 

Paralysis of an abductor on one side may be present without any symp- 
toms. It is more particularly, as Semon states, when the paralytic con- 
tractures supervene that the attention is called to laryngeal symptoms. 

Haemorrhage in thoracic aneurism may come from (a) the soft granula- 
tions in the trachea at the point of compression, in which case the sputa are 
blood-tinged, but large quantities of blood are not lost; (b) from rupture 
of the sac into the trachea or bronchi; (c) from perforation into the lung 
or erosion of the lung tissue. The bleeding may be profuse, rapidly prov- 
ing fatal, and is a common cause of death. It may persist for weeks or 
months, in which case it is simply hemorrhagic weeping through the sac, 
which is exposed in the trachea. In some instances, even after a very 
profuse haemorrhage, the patient recovers and may live for years. A man 
with well-marked thoracic aneurism, whom I showed to my class at the 
University of Pennsylvania and who had had several brisk haemorrhages, 
died four years after, having in the meantime enjoyed average health. 
Death from hemorrhage is relatively more common in aneurism of the 
third portion of the arch and of the descending aorta. 

Difficulty of swallowing is a comparatively rare symptom, and may be 
due either to spasm or to direct compression. The sound should never 
be passed in these cases, as the oesophagus may be almost eroded and a per- 
foration may be made. 

Heart Symptoms. — Pain has been referred to; it is often anginal in 
character, and is most common when the root of the aorta is involved. The 
heart is hypertrophied in less than one half the cases. The aortic valves 



782 



DISEASES OF THE CIRCULATORY SYSTEM. 



are sometimes incompetent, either from disease of the segments or from 
stretching of the aortic ring. 

Among other signs and symptoms, venous compression, which has 
already been mentioned, may involve one subclavian or the superior vena 
cava. A curious phenomenon in intrathoracic aneurism is the clubbing 
of the fingers and incurving of the nails of one hand, of which two ex- 
amples have been under my care, in both without any special distention 
or signs of venous engorgement. Tumors of the arch may involve the 
pulmonary artery, producing compression, or in some instances adhesion 
of the pulmonary segments and insufficiency of the valve; or the sac may 
rupture into the artery, an accident which happened in two of my cases, 
producing instantaneous death. 

Pressure on the sympathetic is particularly liable to occur in growths 
from the ascending portion of the arch. Either the upper dorsal or the 
lower cervical ganglion is involved. The symptoms are variable. If the 
nerve is simply irritated, there is stimulation of the vaso-dilator fibres and 
dilatation of the pupil. With this may be associated pallor of the same 
side of the face. On the other hand, destruction of the cilio-spinal branches 
causes paralysis of the dilator fibres, in consequence of which the iris con- 
tracts, the vessels on the side of the head dilate, causing congestion, and 
in some instances unilateral sweating. It is much more common to see 
the pupillary symptoms alone than in combination either with pallor, red- 
ness, or sweating. 

The clinical picture of aneurism of the aorta is extremely varied. Many 
cases present characteristic symptoms and no physical signs, while others 
have well-marked physical signs and no symptoms. As Broadbent re- 
marks, the aneurism of physical signs springs from the ascending portion 
of the aorta; the aneurism of symptoms grows from the transverse arch. 

Aneurism of the aorta may be confounded with: (a) The violent throb- 
bing impulse of the arch in aortic insufficiency. I have already referred 
to a case of this kind in which the diagnosis of aneurism was made by sev- 
eral good observers. 

(b) Simple Dynamic Pulsation. — No instance of this, which is common 
in the abdominal aorta, has ever come under my notice. One which came 
under the care of William Murray and Bramwell presented, without any 
pain or pressure symptoms, pulsation and dulness over the aorta. The con- 
dition gradually disappeared and was thought to be neurotic. 

(c) Dislocation of the heart in curvature of the spine may cause great 
displacement of the aorta, so that it has been known to pulsate forcibly 
to the right of the sternum. 

(d) Solid Tumors. — When the tumor projects externally and pulsates 
the difficulty may be considerable. In tumor the heaving, expansile pulsa- 
tion is absent, and there is not that sense of force and power which is so 
striking in the throbbing of a perforating aneurism. There is not to be 
felt as in aortic aneurism the shock of the heart-sounds, particularly the 
diastolic shock. Auscultatory sounds are less definite, as large aneurisms 
may occur without murmur; and, on the other hand, murmurs may be 
heard over tumors. The greatest difficulty is in the deep-seated thoracic 



ANEURISM. 



783 



tumors, and here the diagnosis may be impossible. I have already re- 
ferred to the case which was regarded by Skoda as aneurism and by Op- 
polzer as tumor. The physical signs may be indefinite. The ringing 
aortic second sound is of great importance and is rarely, if ever, heard 
over tumor. Tracheal tugging is here a valuable sign. Pressure phe- 
nomena are less common in tumor, whereas pain is more frequent. The 
general appearance of the patient in aneurism is much better than in 
tumor, in which there may be cachexia and enlargement of the glands in 
the axilla or in the neck. Healthy, strong males who have worked hard 
and have had syphilis are the most common subjects of aneurism. Occa- 
sionally cancer of the oesophagus may simulate aneurism, producing pressure 
on the left bronchus. In doubtful cases the X-ray picture may give most 
valuable information as to the situation and relations of the aneurism. 

(e) Pulsating Pleurisy. — In cases of empyema necessitatis, if the pro- 
jecting tumor is in the neighborhood of the heart and pulsates, the condi- 
tion may readily be mistaken for aneurism. The absence of the heaving, 
firm distention and of the diastolic shock would, together with the his- 
tory and the existence of pleural effusion, determine the nature of the case. 
If necessary, puncture may be made with a fine hypodermic needle. In a 
majority of the cases of pulsating pleurisy the throbbing is diffuse and 
widespread, moving the whole side. 

Prognosis. — The outlook in thoracic aneurism is always grave. Life 
may be prolonged for some years, but the patients are in constant jeopardy. 
Spontaneous cure is not very infrequent in the small sacculated tumors of 
the ascending and thoracic portions. The cavity becomes filled with lam- 
inae of firm nbrin, which become more and more dense and hard, the sac 
shrinks considerably, and finally lime salts are deposited in the old fibrin. 
The laminae of fibrin may be on a level with the lumen of the vessel, caus- 
ing complete obliteration of the sac. The cases which rupture externally, 
as a rule run a rapid course, although to this there are exceptions; the 
sac may contract, become firm and hard, and the patient may live for five, 
or even, as in a case mentioned by Balfour, for ten years. The cases which 
have lasted longest in my experience have been those in which a saccular 
aneurism has projected from the ascending arch. One patient in Mont- 
real had been known to have aneurism for eleven years. The aneurism 
may be enormous, occupying a large area of the chest, and yet life be pro- 
longed for many years, as in the case mentioned as under the care of 
Skoda and Oppolzer. One of the most remarkable insfances is the case of 
dissecting aneurism reported by Graham. The patient was invalided after 
the Crimean War with aneurism of the aorta, and for years was under the 
observation of J. H. Richardson, of Toronto, under whose care he died 
in 1885. The autopsy showed a healed aneurism of the arch, with a dis- 
secting aneurism extending the whole length of the aorta, which formed a 
double tube. 

Treatment. — Tn a large proportion of the cases this can only be pal- 
liative. Still in every instance measures should be taken which are known 
to promote clotting and consolidation within the sac. Tn any large series 
of cured aneurisms a considerable majority of the patients have not been 
4U 



784 



DISEASES OF THE CIRCULATORY SYSTEM. 



known to be subjects of the disease, but the obliterated sac has been found 
accidentally at the post mortem. 

The most satisfactory plan in early cases, when it can be carried out 
thoroughly, is that advised by the late Mr. Tufnell, of Dublin, the essen- 
tials of which are rest and a restricted diet. Eest is essential and should, 
as far as possible, be absolute. The reduction of the daily number of 
heart-beats, when a patient is recumbent and makes no exertion whatever, 
amounts to many thousands, and is one of the principal advantages of 
this plan. Mental quiet should also be enjoined. The diet advised by 
Tufnell is extremely rigid — for breakfast, 2 ounces of bread and butter 
and 2 ounces of milk; for dinner, 2 or 3 ounces of meat and 3 or 4 ounces 
of milk or claret; for supper, 2 ounces of bread and 2 ounces of milk. 
This low diet diminishes the blood-volume and is thought also to render 
the blood more fibrinous. It reduces greatly the blood-pressure within 
the sac, in this manner favoring coagulation. This treatment should be 
pursued for several months, but, except in persons of a good deal of mental 
stamina, it is impossible to carry it out for more than a few weeks at a 
time. It is a form of treatment adapted only for the saccular form of 
aneurism, and in cases of large sacs communicating with the aorta by a 
comparatively small orifice the chances of consolidation are fairly good. 
Unquestionably rest and the restriction of the liquids are the important 
parts of the treatment, and a greater variety and quantity of food may 
be allowed with advantage. If this plan cannot be thoroughly carried out, 
the patient should at any rate be advised to live a very quiet life, moving 
about with deliberation and avoiding all sudden mental or bodily excite- 
ment. The bowels should be kept regular, and constipation and strain- 
ing should be carefully avoided. Of medicines, iodide of potassium, as 
advised by Balfour, is of great value. It may be given in doses of from 
10 to 15 or 20 grains three times a day. Larger doses are not necessary. The 
mode of action is not well understood. It may act by increasing the secre- 
tions and so inspissating the blood, by lowering the blood-pressure, or, 
as Balfour thinks, by causing thickening and contraction of the sac. The 
most striking effect of the iodide in my experience has been the relief of 
the pain. The evidence is not conclusive that the syphilitic cases are more 
benefited by it than the non-syphilitic. All these measures have little value 
unless the sac is of a suitable form and size. The large tumors with wide 
mouths communicating with the ascending portion of the aorta may be 
treated on the most approved plans for months without the slightest influ- 
ence other than reduction in the intensity of the throbbing. A patient 
with a tumor projecting into the right pleura remained on the most rigid 
Tufnell treatment for more than one hundred days, during which time he 
also took iodide of potassium faithfully. The pulsations were greatly re- 
duced and the area of dulness diminished, and we congratulated ourselves 
that the sac was probably consolidating. Sudden death followed rupture 
into the pleura, and the sac contained only fluid blood, not a shred of 
fibrin. In cases in which the tumor is large, or in which there seems to be 
very little prospect of consolidation, it is perhaps better to advise a man 
to go on quietly with his occupation, avoiding excitement and worry. Our 



ANEURISM. 



785 



profession has offered many examples of good work, thoroughly and con- 
scientiously carried out, by men with aneurism of the aorta, who wisely, 
I think, preferred, as did the late Hilton Fagge, to die in harness. 

Surgical Measures. — In a few cases consolidation may be promoted in 
the sac by the introduction of a foreign body, such as wire, horse-hair, or 
by the combination of wiring and electrolysis. Moore, in 1864, first wired 
a sac, putting in 78 feet of fine wire. Death occurred on the fifth day. 
Corradi proposed the combined method of wiring with electrolysis, which 
was first used by Burresi in 1879. His patient lived for three and a half 
months. Horse-hair, watch-spring wire, catgut, and Florence silk have 
been used. Hunner reports the statistical results of both methods up to 
October, 1900. With Moore's method (wiring) 14 cases were treated, 8 of 
thoracic aneurism, all fatal; 6 aneurisms of the abdominal aorta, 3 of which 
were successful. Of 23 cases treated by wiring and electrolysis (Moore- 
Corradi method), 17 were thoracic and 6 abdominal. The thoracic cases 
of Eosenstirn, Stewart, and Kerr, and the abdominal cases of Noble and 
Finney (Case V), were successful. In eight of the 23 cases there were 
amelioration of symptoms and probable prolongation of life. The most 
favorable cases are those in which the aneurism is sacculated, but this is 
a point not easily determined, and often from a sac particularly favorable 
for wiring there may be secondary projections of great thinness. The sud- 
den filling by clot of an aneurism of the coeliac axis or of the superior 
mesenteric artery may result fatally from infarct of the intestine. 

Other Symptoms requiring Treatment. — Pressure on veins causing en- 
gorgement, particularly of the head and arms, is sometimes promptly re- 
lieved by free venesection, and at any time during the course of a thoracic 
aneurism, if attacks of dyspnoea with lividity supervene, bleeding may be 
resorted to with great benefit. It has the advantage also of promptly 
checking the pain, for which symptom, as already mentioned, the iodide 
of potassium often gives relief. In the final stages morphia is, as a rule, 
necessary. Dyspnoea, if associated with cyanosis, is best relieved by bleed- 
ing. Chloroform inhalations may be necessary. The question sometimes 
comes up with reference to tracheotomy in these cases of urgent dyspnoea. 
If it can be shown by laryngoscopic examination that it is due to bilateral 
abductor paralysis the trachea may be opened, but this is extremely rare, 
and in nearly every instance the urgent dyspnoea is caused by pressure 
about the bifurcation. When the sac appears etxernally and grows large, 
an ice-cap may be applied upon it, or a belladonna plaster to allay the 
pain. In some instances an elastic support may be used with advantage, 
and I saw a physician with an enormous external aneurism in the right 
mammary region who for many months had obtained great relief by the 
elastic support, passing over the shoulder and under the arm of the oppo- 
site side. 

Digitalis, ergot, aconite, and veratrum viride are rarely, if ever, of serv- 
ice in thoracic aneurism. 



786 



DISEASES OF THE CIRCULATORY SYSTEM. 



Aneurism of the Abdominal Aorta. 

The sac is most common just below the diaphragm in the neighborhood 
of the cceliac axis. This variety is rare in comparison with thoracic aneu- 
rism. Of the 468 cases of aortic aneurism at St. Bartholomew's Hospital, 23 
involved the abdominal aorta. The tumor may be fusiform or sacculated, 
and it is sometimes multiple. Projecting backward, it erodes the vertebrae 
and may cause numbness and tingling in the legs and finally paraplegia, or 
it may pass into the thorax and burst into the pleura. More commonly the 
sac is on the anterior wall and projects forward as a definite tumor, which 
may be either in the middle line or a little to the left. The tumor may 
project in the epigastric region (which is most common), in the left hypo- 
chondrium, in the left flank, or in the lumbar region. When high up 
beneath the pillar of the diaphragm it may attain considerable size without 
being very apparent on palpation. 

The symptoms are chiefly pain, very often of a cardialgic nature, pass- 
ing round to the sides or localized in the back, and gastric symptoms, par- 
ticularly vomiting. Eetardation of the pulse in the femoral is a very com- 
mon symptom. 

Diagnosis and Physical Signs. — Inspection may show marked 
pulsation in the epigastric region, sometimes a definite tumor. A thrill 
is not uncommon. The pulsation is forcible, expansile, and sometimes 
double when the sac is large and in contact with the pericardium. On pal- 
pation a definite tumor can be felt. If large, there is some degree of dul- 
ness on percussion which usually merges with that of the left lobe of the 
liver. On auscultation, a systolic murmur is, as a rule, audible, and is 
sometimes best heard at the back. A diastolic murmur is occasionally 
present, usually very soft in quality. One of the commonest of clinical 
errors is to mistake a throbbing aorta for an aneurism. It is to be remem- 
bered that no pulsation, however forcible, or the presence of a thrill or a 
systolic murmur justifies the diagnosis of abdominal aneurism unless there 
is a definite tumor which can be grasped and which has an expansile pulsa- 
tion. Attention to this rule will save many errors. The throbbing aorta 
— the " preternatural pulsation in the epigastrium," as Allan Burns calls 
it — is met with in all neurasthenic conditions, particularly in women. In 
anaemia, particularly in some instances of traumatic anaemia, the throbbing 
may be very great. In the case of a large, stout man with severe haemor- 
rhages from a duodenal ulcer the throbbing of the abdominal aorta not 
only shook violently the whole abdomen, but communicated a pulsation 
to the bed, the shock of which was distinctly perceptible to any one sitting 
upon it. Very frequently a tumor of the pylorus, of the pancreas, or of 
the left lobe of the liver is lifted with each impulse of the aorta and may 
be confounded with aneurism. The absence of the forcible expansile im- 
pulse and the examination in the knee-elbow position, in which the tumor, 
as a rule, falls forward, and the pulsation is not then communicated, suf- 
fice for differentiation. The tumor of abdominal aneurism, though usually 
fixed, may be very freely movable. 

The outlook in abdominal aneurism is bad. A few cases heal spon- 



ANEURISM. 



taneously. Death may result from (a) complete obliteration of the lumen 
by clots; (b) compression paraplegia; (c) rupture (which is almost the 
rule) either into the pleura, retroperitoneal tissues, peritonaeum, or the in- 
testines, very commonly the duodenum; (d) embolism of the superior mesen- 
teric artery, producing infarction of the intestines. 

The treatment is such as already advised in thoracic aneurism. When 
the aneurism is low down pressure has been successfully applied in a case 
by Murray, of Newcastle. It must be kept up for many hours under chloro- 
form. The plan is not without risk, as patients have died from bruising 
and injury of the sac. 

Aneurism of the Branches of the Abdominal Aorta. 

The cceliac axis is itself not infrequently involved in aneurism of the 
first portion of the abdominal aorta. Of its branches, the splenic artery is 
occasionally the seat of aneurism. This rarely causes a tumor large enough 
to be felt; sometimes, however, the tumor is of large size. I have reported 
a case in a man, aged thirty, who had an illness of several months' dura- 
tion, severe epigastric pain and vomiting, which led his physicians in New 
York to diagnose gastric ulcer. There was a deep-seated tumor in the left 
hypochondriac region, the dulness of which merged with that of the spleen. 
There was no pulsation, but it was thought on one occasion that a bruit 
was heard. The chief symptoms while under observation were vomiting, 
severe epigastric pain, occasional haematemesis, and finally severe haemor- 
rhage from the bowels. An aneurism of the splenic artery the size of a 
cocoa-nut was situated between the stomach above and the transverse colon 
below, and extended to the left as far as the level of the navel. The sac 
contained densely laminated fibrin. It had perforated the colon. I have 
twice seen small aneurisms on the splenic artery. Of 39 instances of aneu- 
rism on the branches of the abdominal aorta collected by Lebert, 10 were 
of the splenic artery. 

Aneurism of the hepatic artery is very rare, and there are only 10 or 12 
cases on record. The symptoms are extremely indefinite; the condition 
could rarely be diagnosed. In the case reported by Eoss and myself, a man 
aged twenty-one had the symptoms of pyaamia. The liver was greatly 
enlarged, weighed nearly 5,000 grammes, and presented innumerable small 
abscesses. An oval aneurism, half the size of a small lemon, involved the 
right and part of the left branches. In J. B. S. Jackson's case the aneu- 
rism perforated the hepatic duct. 

A few cases of aneurism of the superior mesenteric artery are on record. 
The diagnosis is scarcely possible. Plugging of tin 1 branches or of the main 
stein may cause the symptoms of infarction of the bowels which have al- 
ready been considered. 

Renal Artery. — Henry Morris has collected 21 instances of aneurism 
(Lancet, Oct. 0, 15)00), 12 of which arose from injury. Many of them were 
false. Pulsation and a bruit are not always present. Pour cases were 
operated upon; 3 recovered. In a case of Keen's the tumor and the kidnev 
were removed together. 



788 



DISEASES OF THE CIRCULATORY SYSTEM. 



Arterio-venous Aneurism. 

In this form there is abnormal communication between an artery and 
a -vein. When a tumor lies between the two it is known as varicose aneu- 
rism; when there is a direct communication without tumor the vein is 
chiefly distended and the condition is known as aneurismal varix. 

An aneurism of the ascending portion of the arch may open directly 
into the vena cava. Twenty-nine cases of this lesion have been analyzed 
by Pepper and Griffith. Cyanosis, oedema, and great distention of the 
veins of the upper part of the body are the most frequent symptoms, and 
develop, as a rule, with suddenness. Of the physical signs a thrill is pres- 
ent in some cases. A continuous murmur with systolic intensification is 
of great diagnostic value. In a recent case, after the existence for some 
time of pressure symptoms, intense cyanosis developed with engorgement 
of the veins of the head and arms. Over the aortic region there was a 
loud continuous murmur with systolic intensification. 

A majority of the cases of arterio-venous aneurism and of aneurismal 
varix result from the accidental opening of an artery and vein as in vene- 
section, and are met with at the bend of the elbow or sometimes in the 
temporal region. The condition may persist for years without causing 
any trouble. Pulsation, a loud thrill, and a continuous humming murmur 
are usually present. 

Congenital Aneurism, or Periarteritis Nodosa. 

A series of cases has been described in which the lesions are small 
aneurisms on the arteries of the muscles and viscera. The first case was 
reported by Kussmaul and Maier, and three others have been described. 
A fifth case, agreeing clinically with the others, has occurred in my wards. 
No autopsy was permitted, but the nodules were felt in the abdominal wall 
before death. The case is reported by Sabin (J. H. H. Bull., 1901). There 
are marked thickening of the intima and infiltration of the other coats, 
with a nuclear growth almost sarcomatous. There are two theories: one 
that the nodules are aneurisms due to syphilis or to congenital weak- 
ening of the arteries; the other that they are aneurisms secondary to an 
inflammatory process like the infectious granulomata. 

The cases have occurred about equally in men and women between 
the ages of twenty-seven and fifty-two; the course is from eight to 
twelve weeks. The patients complain of weakness. The symptoms 
correspond with the situation of the lesions; thus, their presence in 
the muscles is associated with pain, weakness, and sometimes paralysis 
and atrophy. The nodules are abundant in the alimentary tract. 
The severest symptom is epigastric pain; there is loss of appetite, thirst, 
vomiting, constipation, or diarrhoea. The disease is febrile at first, 
but the temperature sinks to subnormal, while the pulse remains 
rapid. The anaemia is extreme. In our case the haemoglobin was 21 
per cent, the red blood-cells 1,704,000. The leucocytes rose from 50,000 
to 116,000, of which 91 per cent were polymorphonuclear forms. The urine 
is scanty, of low specific gravity, with albumin and casts. Urea is excreted 
in small quantities, but the mind is clear. 



SECTION VIII. 



DISEASES OF THE BLOOD Ai^D DUCTLESS 

GLANDS. 



I. ANAEMIA. 

Ais^mia may be defined as a reduction in the amount of the blood as 
a whole or of its corpuscles, or of certain of its more important constitu- 
ents, such as albumin and haemoglobin. The condition may be general 
or local. The former alone we are here considering. It is interesting to 
note, however, that the pallor, particularly of the face, which is one of the 
most striking symptoms of anaemia, is just as characteristic of local anaemia 
due to fright or to nausea. There are persons persistently pale without 
actual anaemia in whom the condition may be due to inherited peculiarities. 

Our knowledge is not yet sufficiently advanced to classify satisfactorily 
the various forms of anaemia. The following provisional grouping may 
be made: (1) Secondary or symptomatic anaemia; (2) primary, essential, 
or cytogenic anaemia. 

Secondary Anemia. 

Under this division comes a large proportion of all cases. The follow- 
ing are the most important groups, based on the etiology: 

(1) Anosmia from hemorrhage, either traumatic or spontaneous. The 
loss of blood may be rapid, as in lesions of large vessels, in injury or in 
rupture of aneurisms, in cases of ulcer of the stomach or duodenum, or 
in post-partum haemorrhage. If the loss is excessive, death results from 
lowering of the arterial pressure. In sudden profuse haemorrhage the 
loss of 3 or 4 pounds of blood may prove fatal. In the rupture of 
au aneurism into the pleura the loss of blood may amount to 7 J pounds, 
the largest quantity I have known to be shed into one cavity. In 
a case of haematemesis the patient lost over 10 pounds by measurement 
in one week and yet recovered from the immediate effects. Even after very 
severe haemorrhage the number of red blood-corpuscles is not reduced so 
greatly as in forms of idiopathic anaemia. Thus in one ease jnsl mentioned, 
al the termination of the week of bleeding there were nearly 1,390,000 red 
Mood-corpuscles to the cubic millimetre. The process of regeneration goes 
on with great rapidity, and in some "bleeders" a week or ten days suffice 

789 



790 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



to re-establish the normal amount. The watery and saline constituents of 
the blood are readily restored by absorption from the gastro-intestinal 
tract. The albuminous elements also are quickly renewed, but it may 
take weeks or months for the corpuscles to reach the normal standard. The 



no* 
100* 

90% 
80% 
70% 
60% 
50% 

4:0% 

30% 





APRIL. 


MAY. 


JUNE. 


JULY. 






































































































































































5,000,000 














- 






























































































- 




































































































































































































4,000,000 






























































































































































































































































































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3,000,000 














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-& — & — v;— 
























■i 










-1 






























V 




_ .; 








14,000 












































































12,000 












































































10,000 












































































8,000 












































































6,000 














- 


- 




























































4,000 












































































2,000 
















































s 









































































































CORPUSCLES 



BLACK, .REP CORPUSCLES* 



RED, HAEMOGLOBIN. 



BLUE. COLORLESS CORPUSCLES. 



Chart XVII. — Illustrates the rapidity with which anemia is produced in purpura 
hemorrhagica and the gradual recovery.* 



haemoglobin is restored more slowly than the corpuscles. The accompany- 
ing chart illustrates the rapid fall and gradual restitution in a case of severe 
purpura haamorrhagica. 

The microscopical characters of the blood after severe haemorrhage may 
not be greatly changed. The red corpuscles show, usually, rather more 
marked differences in size than normally, while the average size may be a 
trifle reduced; there may be a moderate poikilocytosis. The corpuscles 
are paler than normally. Nucleated red corpuscles appear, almost always, 
soon after the haemorrhage; they are, however, not numerous. These are 
small bodies of about the same size as a normal red corpuscle with a small, 



* On September 27th the patient returned from the oountry, where she had spent 
the summer. The blood-count was then : Red corpuscles, 5,350,000 ; white corpuscles, 
5,500 ; haemoglobin, 94 per cent. 



ANiEMIA. 



791 



round, deeply staining nucleus. Free nuclei may be found. The color- 
less corpuscles are, at first, increased in number. There is a moderate 
leueocytosis, the differential count showing an increase in the multinuclear 
neutrophils with a diminution in the small mononuclear elements. Dur- 
ing recovery the leueocytosis diminishes. 

The reduction in haemoglobin is always proportionately greater than 
that in the corpuscles. 

In some instances a rapidly fatal anaemia may follow a single severe 
haemorrhage, or repeated small haemorrhages as in purpura. Here the 
appearances of the red corpuscles are much the same, except in the total 
absence of nucleated red corpuscles. 

The leucocytes in these cases are usually reduced in number; the poly- 
nuclear elements are present in a relatively diminished proportion, while 
the small mononuclear forms are numerous. The autopsy, in these cases, 
reveals usually a total absence of any regenerative activity on the part of 
the bone-marrow. 

(2) Anaemia is frequently produced by long-continued drain on the t 
albuminous materials of the blood, as in chronic suppuration and Bright's 
disease. Prolonged lactation acts in the same way. Eapidly growing 
tumors may cause a profound anaemia, as in gastric cancer. The charac- 
ters of the blood here may be much the same as in the acute cases. Usu- 
ally, though, the poikilocytosis is much more marked; in severe cases it 
may be excessive. The presence, however, of the very large corpuscles, 
such as one sees in pernicious anaemia, is not noted, the average size ap- 
pearing to be rather smaller than normal. 

Nucleated red corpuscles are usually scanty. In long-continued chronic 
secondary anaemias occasional larger nucleated red corpuscles may be seen, 
bodies with larger palely staining nuclei; in some of these cells karyo- 
kinetic figures occur. Nucleated red corpuscles with fragmentary nuclei 
may also be seen. 

The leucocytes may be increased in number, though in some severe 
chronic cases there may be a diminution. 

(3) Ancemia from Inanition. — This may be brought about by defective 
food supply, or by conditions which interfere with the proper reception 
and preparation of the food, as in cancer of the oesophagus and chronic 
dyspepsia. The reduction of the blood mass may be extreme, but the 
plasma suffers proportionately more than the corpuscles, which, even in the 
wasting of cancer of the oesophagus, may not be reduced more than one 
half or three fourths. In some instances the reduction in the plasma may 
be so great that the corpuscles show an apparent increase. 

(4) Toxic ancemia, induced by the action of certain poisons on the 
blond, such as lead, mercury, and arsenic, among inorganic substances, 
and the virus of syphilis and malaria among organic poisons. They act 
either by directly destroying the red blood-corpuscles, as in malaria, or by 
increasing the rate of ordinary consumption. The anaemia of pyrexia 
may in part be dne to a toxic action, but is also caused in part by the dis- 
turbance of digestion and interference with the function of the blood- 
making organs. 



792 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



Peimaby oe Essential Anaemia. 
1. Chlorosis. 

Definition. — An anaemia of unknown cause, occurring in young girls, 
characterized by a marked relative diminution of the haemoglobin. 

Etiology. — It is a disease of girls, more often of blondes than of 
brunettes. It is doubtful if males are ever affected. I have never seen true 
chlorosis in a boy. The age of onset is between the fourteenth and seven- 
teenth years; under the age of twelve cases are rare. Kecurrences, which 
are common, may extend into the third decade. Of the essential cause of 
the disease we know nothing. There exists a lowered energy in the blood- 
making organs, associated in some obscure way with the evolution of the 
sexual apparatus in women. Hereditary influences, particularly chlorosis 
and tuberculosis, play a part in some cases. Sometimes, as Virchow pointed 
out, the condition exists with a defective development (hypoplasia) of the 
circulatory and generative organs. 

The disease is most common among the ill-fed, overworked girls of 
large towns, who are confined all day in close, badly lighted rooms, or 
have to do much stair-climbing. Cases are frequent, however, under the 
most favorable conditions of life. Lack of proper exercise and of fresh air, 
and the use of improper food are important factors. Emotional and nerv- 
ous disturbances may be prominent — so prominent that certain writers have 
regarded the disease as a neurosis. De Sauvages speaks of a chlorose par 
amour. Newly arrived Irish girls were very prone to the 1 disease in Mont- 
real. The " corset and chlorosis " expresses 0. Kosenbaclr's opinion. Men- 
strual disturbances are not uncommon, but are probably a sequence, not a 
cause, of chlorosis. Sir Andrew Clark believed that constipation plays an 
important role, and that the condition is in reality a coprcemia due to the 
absorption of poisons — leucomaines and ptomaines — from the large bowel, 
a view which always appeared to me baseless, considering the great fre- 
quency of the condition in women. 

Symptoms.— (a) General. — The symptoms of chlorosis are those of 
anaemia. The subcutaneous fat is well retained or even increased in 
amount. The complexion is peculiar; neither the blanched aspect of haem- 
orrhage nor the muddy pallor of grave anaemia, but a curious yellow-green 
tinge, which has given to the disease its name, and its popular designation, 
the green sickness. Occasionally the skin shows areas of pigmentation, 
particularly about the joints. In cases of moderate grade the color may 
be deceptive, as the cheeks have a reddish tint, particularly on exertion 
(chlorosis rubra). The subjects complain of breathlessness and palpita- 
tion, and there may be a tendency to fainting — symptoms which often 
lead to the suspicion of heart or lung disease. Pumness of the face and 
swelling of the ankles may suggest nephritis. The disposition often 
changes, and the girl becomes low-spirited and irritable. The eyes have 
a peculiar brilliancy and the sclerotics are of a bluish color. 

(#) Special Features. — Blood. — The drop as expressed looks pale. 
Johann Duncan, in 1867, first called attention to the fact that the essen- 



ANAEMIA. 



793 



tial feature was not a great reduction in the number of the corpuscles, but 
a quantitative change in the haemoglobin. The corpuscles themselves look 
pale. In 63 consecutive cases examined at my clinic by Thayer, the average 
number per cubic millimetre of the red blood-corpuscles was 4,096,544, 
or over 80 per cent, whereas the percentage of haemoglobin for the total 
number was 42.3 per cent. The accompanying chart illustrates well these 
striking differences. There may, however, be well-marked actual anaemia. 
The lowest blood-count in the series of cases referred to above was 1,932,000. 
There may be all the physical characteristics and symptoms of a profound 
anaemia with the number of the blood-corpuscles nearly at the normal 



120% 
110% 
100% 
90% 
80% 
70% 
00% 
50% 
40% 
30% 
20% 





JANUARY. 


FEBRUARY.. 


MARCH. 




























































































6,000,000 












































/ 
r 
















































































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4,000,000 






































































































































































































































































































— 


































3,000,000 








































































































































































































































































































































2,000,000 








































































































































































































































































































































1,000,000 


- 
















































































— £ — 


















































































14,000 


















































































12,000 


















































































10,000 


















































































8,000 


















































































0.000 


















































































4,000 
















































































2,000 





































































































































































MEAN NORM. 
NUMBER Or 
WHITE 
CORPUSCLES 



BLACK, RED CORPUSCLES. RED, HAEMOGLOBIN. 

Chart XVIII. — Chlorosis. 



BLUE, COLORLESS CORPUSCLES. 



standard. Thus in one instance the globular richness was over 85 per 
cent, with the haemoglobin about 35. No other form of anaemia presents 
this feature, at least with the same constancy and in the same degree. The 
importance of the reduction in the haemoglobin depends upon the fact that 



794 DISEASES OP THE BLOOD AND DUCTLESS GLANDS. 



it is the iron-containing elements of the blood with which in respiration 
the oxygen enters into combination. This marked diminution in the iron 
has also been determined by chemical analysis of the blood. The micro- 
scopical characteristics of the blood are as follows: In severe cases the 
corpuscles may be extremely irregular in size and shape — poikilocytosis, 
which may occasionally be as marked as in some cases of pernicious anaemia. 
The large forms of red blood-cells are not as common, and the average 
size is stated to be below normal. The color of the corpuscles is noticeably 
pale and the deficiency may be seen either in individual corpuscles or in 
the blood mixture prepared for counting. Nucleated red corpuscles (normo- 
blasts) are not very uncommon, and may vary greatly in numbers in the 
same case at different periods. The leucocytes may show a slight increase; 
the average in the 63 cases above referred to was 8,467 per cubic millimetre. 

(c) Gastro-intestinal Symptoms. — The appetite is capricious, and pa- 
tients often have a longing for unusual articles, particularly acids. In 
some instances they eat all sorts of indigestible things, such as chalk or 
even earth. Superacidity of the gastric juice is commonly associated with 
chlorosis. In 19 out of 21 cases in Kiegel's clinic this condition was found 
to exist. In the other two instances the acidity was normal or a trifle in- 
creased. Distress after eating and even cardialgic attacks may be associ- 
ated with it. Constipation is a common symptom, and, as already men- 
tioned, has been regarded as an important element in causing the disease. 
A majority of chlorotic girls who wear corsets have gastroptosis, and on 
inflation the stomach will be found vertically placed; sometimes the organ 
is very much dilated. The motor power is usually well retained. Enter- 
optosis with palpable right kidney is not uncommon. 

(d) Circulatory Symptoms. — Palpitation of the heart occurs on exer- 
tion, and may be the most distressing symptom of which the patient com- 
plains. Percussion may show slight increase in the transverse dulness. A 
systolic murmur is heard at the apex or at the base; more commonly at 
the latter, but in extreme cases at both. A diastolic murmur is rarely 
heard. The systolic murmur is usually loudest in the second left inter- 
costal space, where there is sometimes a distinct pulsation. The exact 
mode of production is still in dispute. Balfour holds that it is produced 
at the mitral orifice by relative insufficiency of the valves in the dilated 
condition of the ventricle. On the right side of the neck over the jugular 
vein a continuous murmur is heard, the bruit de diable, or humming-top 
murmur. 

The pulse is usually full and soft. Pulsation in the peripheral veins is 
sometimes seen. There is a tendency to thrombosis in the veins; most 
commonly in the femoral, but in other instances in the longitudinal sinus; 
or the thrombosis may be multiple. Leichtenstern has found that of 86 
cases of thrombosis in chlorosis the veins of the lower extremities were 
affected 48 times and the cerebral sinuses 29 times. The chief danger in 
thrombosis of the extremities is pulmonary embolism, which occurred in 13 
of 52 cases collected by Welch. 

As in all forms of essential anaemia, fever is not uncommon. Especial 
attention has of late been directed to this by French writers. Chlorotic 



ANAEMIA. 



795 



patients suffer frequently from headache and neuralgia, which may be 
paroxysmal. The hands and feet are often cold. Dermatographia is com- 
mon. Hysterical manifestations are not infrequent. Menstrual disturb- 
ances are very common — amenorrhoea or dysmenorrhea. With the im- 
provement in the blood condition this function is usually restored. 

Diagnosis. — The green sickness, as it is sometimes called, is in many 
instances recognized at a glance. The well-nourished condition of the 
girl, the peculiar complexion, which is most marked in brunettes, and the 
white or bluish sclerotics are very characteristic. A special danger exists 
in mistaking the apparent anaemia of the early stage of pulmonary tuber- 
culosis for chlorosis. Mistakes of this sort may often be avoided by the very 
simple test furnished by allowing a drop of blood to fall on a white towel 
or a piece of blotting paper — a deficiency in haemoglobin is readily appre- 
ciated. The palpitation of the heart and shortness of breath frequently 
suggest heart-disease, and the oedema of the feet and general pallor cause 
the cases to be mistaken for Bright's disease. In the great majority of 
cases the characters of the blood readily separate chlorosis from other 
forms of anaemia. 

2. Idiopathic or Progressive Pernicious Anaemia. 

The disease was first clearly described by Addison, who called it idio- 
pathic anaemia. Channing and Gusserow described the cases occurring 
post partum, but to Biermer we owe a revival of interest in the subject. 

Etiology. — The existence of a separate disease worthy of the term pro- 
gressive pernicious anaemia has been doubted, but there are unquestionably 
cases in which, as Addison says, there exist none of the usual causes or 
concomitants of anaemia. Clinically there are several different groups 
which present the characters of a progressive and pernicious anaemia and 
are etiologically different. Thus, a fatal anaemia may be due to the pres- 
ence of parasites, or may follow haemorrhage, or be associated with chronic 
atrophy of the stomach; but when we have excluded all these causes there 
remains a group which, in the words of Addison, is characterized by a 
" general anaemia occurring without any discoverable cause whatever, cases 
in which there had been no previous loss of blood, no exhausting diarrhoea, 
no chlorosis, no purpura, no renal, splenic, miasmatic, glandular, strumous, 
or malignant disease." 

Idiopathic anaemia is widely distributed. It is of frequent occurrence 
in the Swiss cantons, and it is not uncommon in this country. It affects 
middle-aged persons, but instances in children have been described. Griffith 
mentions about 10 cases occurring'uncler twelve years of age. The youngest 
patient I have seen was a boy of ten. Males are more frequently affected 
than females. Of 40 cases in my wards, 32 were males and 8 wore females. 
Two were colored. Of 550 cases collected by Col man, 323 were in men and 
227 in women. Sinkler and Eshner give 3 cases in one family, the father 
and two girls. 

With the following conditions may be associated a profound anaemia 
not to be distinguished clinically from Addison's idiopathic form: 



796 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



(a) Pregnancy and Parturition. — The symptoms may develop during 
pregnancy, as in 19 of 29 cases of this group in Eichhorst's table. More 
commonly, in my experience, the condition has been post partum; thus, 
of my 27 cases, 5 followed delivery. 

(b) Atrophy of the Stomach. — This condition, early recognized by Flint 
and Fenwick, may certainly cause a progressive pernicious anaemia. By 
modern methods it may now be possible to exclude this extreme gastric 
atrophy. 

(c) Parasites. — The most severe form may be due to the presence of 
parasites, and the accounts of cases depending upon the anchylostoma and 
the bothriocephalus describe a progressive and often pernicious anaemia. 

After the exclusion of these forms there remains a large proportion, 
numbering 18 cases in my series, which correspond to Addison's descrip- 
tion. The etiology of these cases is still dark. The researches of Quincke 
and his student Peters showed that there was an enormous increase in the 
iron in the liver, and they suggested that the affection was probably due to 
increased haemolysis. This has been strongly supported by the extensive 
observations of Hunter, who has also shown that the urine excreted is 
darker in color and contains pathological urobilin. The lemon tint of the 
skin or the actual jaundice is attributed, on this view, to an overproduction. 
To explain the haemolysis, it has been thought that in the condition of 
faulty gastro-intestinal digestion, which is so commonly associated with 
these cases, poisonous materials are developed, which when absorbed cause 
destruction of the corpuscles. Certainly the evidence for haemolysis is 
very strong, but we are still far away from a full knowledge of the condi- 
tions under which it is produced. 

Stockman suggests that repeated small capillary haemorrhages — chiefly 
internal — play an important role in the causation of the disease, which 
also explains, he holds, the existence of a great excess of iron in the liver. 

On the other hand, F. P. Henry, Stephen Mackenzie, Eindfleisch, and 
other authorities incline to the belief that the essence of the disease is in 
defective haemogenesis, in consequence of which the red blood-corpuscles 
are abnormally vulnerable. William Hunter has advanced the view that it 
is a special infective disease associated often with infection of the ali- 
mentary tract and frequently with oral sepsis. 

Morbid Anatomy. — The body is rarely emaciated. A lemon tint 
of the skin is present in a majority of the cases. The muscles often are 
intensely red in color, like horse-flesh, while the fat is light yellow. Haem- 
orrhages are common on the skin and serous surfaces. The heart is usu- 
ally large, flabby, and empty. In one instance I obtained only 2 drachms 
of blood from the right heart, and between 3 and 4 from the left. The 
muscle substance of the heart is intensely fatty, and of a pale, light-yellow 
color. In no affection do we see more extreme fatty degeneration. The 
lungs show no special changes. The stomach in many instances is normal, 
but in some cases of fatal anaemia the mucosa has been extensively atro- 
phied. In the case described by Henry and myself the mucous membrane 
had a smooth, cuticular appearance, and there was complete atrophy of 



ANAEMIA. 



797 



the secreting tubules. The liver may be enlarged and fatty. In most of 
my autopsies it was normal in size, but usually fatty. The iron is 
in excess, a striking contrast to the condition in cases of secondary anaemia. 
It is deposited in the outer and middle zones of the lobules, and in two 
specimens, which I examined, seemed to have such a distribution that the 
bile capillaries were distinctly outlined. This, Hunter states, is a special 
and characteristic lesion, possibly peculiar to pernicious anaemia. A. J. 
Scott examined for me the livers in 45 consecutive autopsies without finding 
(except in pernicious anaemia) this special distribution of pigment. 

The spleen shows no important changes. In one of Palmer Howard's 
cases the organ weighed only 1 ounce and 5 drachms. The iron pigment 
is usually in excess. The lymph-glands may be of a deep red color. The 
amount of iron pigment is increased in the kidneys, chiefly in the convo- 
luted tubules. The bone marrow, as pointed out by H. C. Wood, is usually 
red, lymphoid in character, showing great numbers of nucleated red cor- 
puscles, especially the larger forms called by Ehrlich gigantoblasts. Changes 
in the ganglion cells of the sympathetic have been reported on several oc- 
casions. Lichtheim has found sclerosis in the posterior columns of the 
cord. Burr described a series of cases. The subject is referred to again 
under diseases of the spinal cord (University Med. Magazine, 1895). 

Symptoms. — The patient may have been in previous good health, 
but in many cases there is a history of gastro-intestinal disturbance, mental 
shock, or worry. The description given by Addison presents the chief 
features of the disease in a masterly way. " It makes its approach in so 
slow and insidious a manner that the patient can hardly fix a date to the 
earliest feeling of that languor which is shortly to become so extreme. 
The countenance gets pale, the whites of the eyes become pearly, the gen- 
eral frame flabby rather than wasted, the pulse perhaps large, but remark- 
ably soft and compressible, and occasionally with a slight jerk, especially 
under the slightest excitement. There is an increasing indisposition to 
exertion, with an uncomfortable feeling of faintness or breathlessness in 
attempting it; the heart is readily made to palpitate; the whole surface 
of the body presents a blanched, smooth, and waxy appearance; the lips, 
gums, and tongue seem bloodless, the flabbiness of the solids increases, the 
appetite fails, extreme languor and faintness supervene, breathlessness 
and palpitations are produced by the most trifling exertion or emotion; 
some slight oedema is probably perceived about the ankles; the debility 
becomes extreme — the patient can no longer rise from bed; the mind oc- 
casionally wanders; he falls into a prostrate and half-torpid state, and at 
length expires; nevertheless, to the very last, and after a sickness of several 
months' duration, the bulkiness of the general frame and the amount of 
obesity often present a most striking contrast to the failure and exhaustion 
observable in every other respect." 

The Blood. — The red corpuscles may fall to one fifth or less of the nor- 
mal number. The average count in my 40 hospital cases was 1. 500, 000 
per cubic millimetre, and the haemoglobin was about 30 per cent. The 
haemoglobin is relatively increased, so that the individual globular rich- 
ness is plus, a condition exactly the opposite to that which occurs in 



798 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



chlorosis and the secondary anaemia, in which the corpuscular richness in 
coloring matter is minus. The relative increase in the haemoglobin is 
probably associated with the average increase in the size of the red blood- 
corpuscles. The accompanying chart illustrates these points. Microscop- 
ically the red blood-corpuscles present a great variation in size, and there 
can be seen large giant forms, megalocytes, which are often ovoid in form, 



110% 

100% 
90% 
80% 
70% 
60% 
50% 
40% 
30% 
20% 
10% 





FEB. 


MAR. 


APR. 




JUNE 


JULY 


AUG. 


SEPT. OCT. 


















































































































































































5,000,000 
































































































































































































































































































































4,000,000 
































































































































































































































































r 

































































3,000,000 














/ 










































































































































































































































r 

l 








































































2,000,000 






















































































/ 










































































































































































































































1,000,000 
































































































































































500,000 
















































































8,000 




















-- 
































V.— 


















— •"■ 










6,000 
















































































4,000 
















































































2,000 


















































































































- 













































110% 
100% 
90% 
80% 
70% 
60% 
50%" 
40% 
30% 
20% 
10% 



MEAN NORM. 
NUMBER OF 

WHITE 
CORPUSCLES 



BLACK, RED CORPUSCLES. 



RED, HAEMOGLOBIN. 

Chart XIX. — Pernicious anaemia. 



BLUE, COLORLESS CORPUSCLES. 



measuring 8, 11, or even 15 /x in diameter — a circumstance which Henry 
regards as indicating a reversion to a lower type. Laache thinks these 
pathognomonic, and they certainly form a constant feature. There are 
also small round cells, microcytes, from 2 to 6 jjl in diameter, and of a 
deep red color. The corpuscles show a remarkable irregularity in form; 
they are elongated and rodlike or pyriform; one end of a corpuscle may 



ANJEMIA. 



799 



retain its shape while the other is narrow and extended. To this condition 
of irregularity Quincke gave the name poikilocytosis. 

Nucleated red blood-corpuscles are almost always present, as pointed 
out by Ehrlich. It may require a long search to find them. There are 
two types, normoblasts and megaloblasts, which Ehrlich regards as almost 
distinctive of this anaemia. There are frequently forms intermediate be- 
tween these two groups which often have irregular nuclei. A relatively 
large number of megaloblasts usually indicates a grave outlook. Though 
these large forms are most characteristic, occasionally forms closely similar 
to them may be found in the graver secondary anaemias — e. g., bothrio- 
cephalus anaemia, anchylostomiasis — and in leukaemia. Karyokinetic fig- 
ures may be seen in these bodies. Red corpuscles with fragmenting nuclei 
are common in pernicious anaemia. The leucocytes are generally normal 
or diminished in number; and a marked relative increase in the small mono- 
nuclear forms, with a diminution in the polynuclear leucocytes, is often 
noted. The blood-plates are either absent or very scanty. 

The cardio-vascular symptoms are important and are noted in the de- 
scription given above. Haemic murmurs are usually present. The larger 
arteries pulsate visibly and the throbbing in them may be distressing to the 
patient. The pulse is full and frequently suggests the water-hammer beat 
of aortic insufficiency. The capillary pulse is frequently to be seen. The 
superficial veins are often prominent, and I have seen well-marked pulsa- 
tion in them. Haemorrhages occurred, either in the skin or from the 
mucous surfaces, in 12 cases of my series. Eetinal haemorrhages are com- 
mon. There are rarely symptoms in the respiratory organs. 

Gastro-intestinal symptoms, such as dyspepsia, nausea, and vomiting, 
may be present throughout the disease. Diarrhoea is not infrequent. The 
urine is usually of a low specific gravity and sometimes pale, but in other 
instances it is of a deep sherry color, shown by Hunter and Mott to be 
due to great excess of urobilin. Fever was present in three fourths of 
my cases. Nervous symptoms were found in 14 out of 40 cases. The 
commonest were sensory disturbances with a spastic condition. Pigmenta- 
tion of the skin was present in 8 cases. It is often patchy and associated 
with leucoderma. 

Diagnosis. — From chlorosis the disease is readily distinguished. Sev- 
eral points in the blood examination are of especial importance, namely, 
the relative increase in the haemoglobin and the presence of megalocytes 
and of the large forms of nucleated red blood-corpnscles, the gigantoblasta 
of Ehrlich. Poikilocytosis may occur in any severe anaemia. The marked 
secondary anaemia of cancer of the stomach may give difficulty. In this 
there are usually the features of a secondary anaemia: the red count is 
rarely so low and the gastric findings are of help. The lower red count 
of pernicious anaemia, the high color index, higher percentage of Bmall 
mononuclears, and especially the finding of megaloblasts, are all important 
points. 

Prognosis. — In the true Addisonian cases the outlook is bad, though 
of late years on the arsenic treatment the proportion of recovery has in- 
creased. Of the 40 cases from my wards, death occurred in IT while under 



800 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



observation. The average duration of these was one year. In 8 the course 
was less than six months. The average duration of 22 cases, the majority 
of which were discharged improved or well, had been sixteen months. One 
patient recovered completely. He was admitted in 1890 with a history of 
one year, was discharged well, and returned in 1896 with cancer of the 
stomach. One patient is in good health six years and another four years 
after the onset. In Pye-Smith's article in the Guy's Hospital Eeports he 
mentions 20 cases of recovery. Colman, in a recent article, states that 
one of these cases treated with arsenic in 1880 was alive and well in March, 
1900. The history is usually not one of progressive advance but of alter- 
nate periods of gain and loss. Yet in 6 of my cases the course was practically 
progressive throughout, and in 2 it might be termed acute. In my series 
a red count below one million has been a bad omen. Of 16 such only 4 
recovered. The presence of many megaloblasts is unfavorable. They were 
relatively eleven times more numerous in the fatal cases of my series than 
in those that recovered. That a large relative percentage of small mono- 
nuclears was of bad import is not supported by my cases. Those that recov- 
ered had a slightly higher average percentage than the fatal cases. Pa- 
tients who do not take arsenic will usually do badly. Gastro-intestinal 
disturbances are serious. Only 4 of my cases reached a red count of over 
four million. 

Treatment of Anaemia. — Secondary Anosmia. — The traumatic 
cases do best, and with plenty of good food and fresh air the blood is 
readily restored. The extraordinary rapidity with which the normal per- 
centage of red blood-corpuscles is reached without any medication what- 
ever is an important lesson. The cause of the haemorrhage should be 
sought and the necessary indications met. The large group depending 
on the drain on the albuminous materials of the blood, as in Bright's dis- 
ease, suppuration, and fever, is difficult to treat successfully, and so long 
as the cause keeps up it is impossible to restore the normal blood condition. 
The anaemia of inanition requires plenty of nourishing food. When de- 
pendent on organic changes in the gastro-intestinal mucosa not much 
can be expected from either food or medicine. In the toxic cases due to 
mercury and lead, the poison must be eliminated and a nutritious diet 
given with full doses of iron. In a great majority of these cases there is 
deficient blood formation, and the indications are briefly three: plenty of 
food, an open-air life, and iron. As a rule it makes but little difference 
what form of the drug is administered. 

The treatment of chlorosis affords one of the most brilliant instances — ■ 
of which we have but three or four — of the specific action of a remedy. 
Apart from the action of quinine in malarial fever, and of mercury and 
iodide of potassium in syphilis, there is no other drug the beneficial effects 
of which we can trace with the accuracy of a scientific experiment. It 
is a minor matter how tbe iron cures chlorosis. In a week we give to a 
case as much iron as is contained in the entire blood, as even in the worst 
case of chlorosis there is rarely more than a deficit of 2 grammes of this 
metal. Iron is present in the faeces of chlorotic patients before they are 
placed upon any treatment, so that the disease does not result from any 



ANEMIA. 



801 



deficiency of available iron in the food. Bunge believes that it is the sul- 
phur which interferes with the digestion and assimilation of this natural 
iron. The sulphides are produced in the process of fermentation and 
decomposition in the fasces, and interfere with the assimilation of the 
normal iron contained in the food. By the administration of an inorganic 
preparation of iron, with which these sulphides unite, the natural organic 
combinations in the food are spared. In studying a number of charts of 
chlorosis, it is seen that there is an increase in the red blood-corpuscles 
under the influence of the iron, and in some instances the globular rich- 
ness rises above normal. The increase in the haemoglobin is slower and 
the maximum percentage may not be reached for a long time. I have for 
years in the treatment of chlorosis used with the greatest success Bland's 
pills, made and given according to the formula in Niemeyer's text-book, 
in which each pill contains 2 grains of the sulphate of iron. During the 
first week one pill is given three times a day; in the second week, two 
pills; in the third week, three pills, three times a day. This dose should 
be continued for four or five weeks at least before reduction. An impor- 
tant feature in the treatment of chlorosis is to persist in the use of the 
iron for at least three months, and, if necessary, subsequently to resume 
it in smaller doses, as recurrences are so common. The diet should con- 
sist of good, easily digested food. Special care should be directed to the 
bowels, and if constipation is present a saline purge should be given each 
morning. Such stress did Sir Andrew Clark lay on the importance of con- 
stipation in chlorosis, that he stated that if limited to the choice of one 
drug in the treatment of the disease he would choose a purgative. The 
good influence of alkaline waters in association with the treatment by iron 
has been noted by von Jaksch. In many instances the dyspeptic symptoms 
may be relieved by alkalies. Dilute hydrochloric acid, manganese, phos- 
phorus, and oxygen have been recommended. Best in bed is important in 
severe cases. 

Treatment of Pernicious Anaemia. — Since the introduction by Byrom 
Bramwell of arsenic in this affection a large number of cases have been 
temporarily, a few permanently, cured by it. It should be given as Fowler's 
solution in increasing doses. It is usually well borne, and patient, as a 
rule, take up to 20 minims three times a day without any disturbance. 
I usually begin with 3 minims and increase to 5 at the end of the first 
week, to 10 at the end of the second week, to 15 at the end of the third 
week, and, if necessary, go up to 20 or 25. Symptoms of an over-dose are 
rare; vomiting and diarrhoea occasionally occur. The drug should be dis- 
continued for a few days. Acting on Hunter's suggestion thai the disease 
is a septic infection, oral and intestinal antiseptics may be used. Anti- 
streptococcic serum has been given in some instances. 

Rest in bed and a light but nutritious diet (giving the food in small 
amounts and at fixed intervals) are the first indications. 1 always prefer 
to begin the treatment of a case of pernicious anaemia, whatever the grade 
may be, with rest in bed as one of the essential elements. The patient 
should be out of doors if possible. The beneficial effect of massage has 
been shown by J. K. Mitchell. I have abandoned the use of rectal injections 



802 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



of dried blood. Iron rarely acts well in this form, but in a case in which 
the arsenic disagrees it may be tried. Bone marrow has been recommended. 
It is best given as a glycerin extract. I have not seen any benefit follow 
its administration. Inhalations of oxygen may be tried. 



H. LEUKAEMIA. 

Definition. — An affection characterized by persistent increase in the 
white blood-corpuscles, associated with changes, either alone or together, 
in the spleen, lymphatic glands, or bone marrow. 

The disease was described almost simultaneously by Virchow and by 
Bennett, who gave to it the name leucocythaemia. It is ordinarily -seen in 
two main types, though combinations and variations may occur: 

(1) Spleno-medullary leukaemia, in which the changes are especially 
localized in the spleen and the bone marrow, while the blood shows a great 
increase in elements which are derived especially from the latter tissue, 
a condition which Miiller has termed " myelaemia." Ehrlich prefers to 
call this type of the disease " myelogenous leukaemia," believing the part 
played by the spleen in the process to be purely passive. 

(2) Lymphatic leukaemia, in which the changes are chiefly localized in 
the lymphatic apparatus, the blood showing an especial increase in those 
elements derived from the lymph-glands. 

Etiology. — We know nothing of the conditions under which the dis- 
ease develops. It is not uncommon on this continent. There have been 
24 cases in my wards, of which 15 were of the spleno-myelogenous and 9 
of the lymphatic type. There were 13 males and 11 females. Three were 
colored. There were 18 below the age of forty years. It does not seem 
more frequent in the southern parts of the country. The disease is most 
common in the middle period of life. The youngest of my patients was 
a child of eight months, and cases are on record of the disease as early 
as the eighth or tenth week. It may occur as late as the seventieth year. 
Males are more prone to the affection than females. Birch-Hirschfeld 
states that of 200 cases collected from the literature, 135 were males and 
65 females. 

A tendency to haemorrhage has been noted in many cases, and some 
of the patients have suffered repeatedly from nose-bleeding. In women 
the disease is most common at the climacteric. There are instances in 
which it has developed during pregnancy. The case described by J. Chal- 
mers Cameron, of Montreal, is in this respect remarkable, as the patient 
passed through three pregnancies, bearing on each occasion non-leukaemic 
children. The case is interesting, too, as showing the hereditary character 
of the affection, as the grandmother and mother, as well as a brother, suf- 
fered from symptoms strongly suggestive of leukaemia. One of the pa- 
tient's children had leukaemia before the mother showed any signs, and a 
second died of the disease. At the last report this patient had gradually 
recovered from the third confinement, and the red blood-corpuscles had 
risen to 4,000,000 per cubic millimetre, and the ratio of white to red was 1 



LEUKAEMIA. 



803 



to 200. Sanger has reported a case in which a healthy mother bore a 
leukemic child. 

Malaria is believed by some to be an etiological factor. Of 150 cases 
analyzed by Gowers, there was a history of malaria in 30; of my hospital 
cases 7 gave a history of it. The disease has followed injury or a blow. 
The lower animals are subject to the affection, and cases have been de- 
scribed in horses, clogs, oxen, cats, swine, and mice. Lowit has described a 
parasite which he terms hsemamceba leukaemia?. He describes two varie- 
ties. His views have met with little acceptance. 

Morbid Anatomy. — The wasting may be extreme, and dropsy is 
sometimes present. There is in many cases a remarkable condition of 
polyamria; the heart and veins are distended with large blood-clots. In 
Case XI of my series the weight of blood in the heart chambers alone was 
620 grammes. There may be remarkable distention of the portal, cerebral, 
pulmonary, and subcutaneous veins. The blood is usually clotted, and 
the enormous increase in the leucocytes gives a pus-like appearance to the 
coagula, so that it has happened more than once, as in Virchow's memor- 
able case, that on opening the right auricle the observer at first thought 
he had cut into an abscess. The coagula have a peculiar greenish color, 
somewhat like the fat of a turtle. The alkalinity of the blood is dimin- 
ished. The fibrin is increased. The character of the corpuscles will be 
described under the symptoms. Charcot's octoheclral crystals may separate 
from the blood after death. The specific gravity of the blood is some- 
what lowered. There may be pericardial ecchymoses. 

In the spleno-medullary form the spleen is greatly enlarged. Strong 
adhesions may unite it to the abdominal wall, the diaphragm, or the stom- 
ach. The capsule may be thickened. The vessels at the hilus are enlarged; 
the weight may range from 2 to 18 pounds. The organ is in a condition 
of chronic hyperplasia. It cuts with resistance, has a uniformly reddish- 
brown color, and the Malpighian bodies are invisible. Grayish-white, cir- 
cumscribed, lymphoid tumors may occur throughout the organ, contrasting 
strongly with the reddish-brown matrix. In the early stage the swollen 
spleen pulp is softer, and it is stated that rupture has occurred from the 
intense hyperemia, 

In association with these changes in the spleen, the bone marrow is 
involved, the lieno-medullary form of the Germans. The essential change, 
indeed, in the disease appears to be the extraordinary hyperplasia of the 
red marrow, and the appearance of an hyperplastic cellular tissue in regions 
where in the adults the marrow is fatty. Instead of a fatty tissue, the 
medulla of the long bones may resemble the consistent matter which 
forms the core of an abscess, or it may be dark brown in color, hi Pon- 
fick's case there were hacmorrhagic infarctions. There may he much ex- 
pansion of the shell of bone, and localized swellings which are tender and 
may even yield to firm pressure. Histologically, there are found in the 
medulla large numbers of nucleated red corpuscles in all stages of develop- 
ment, numerous cells with eosinophilic granules, both small polynuclear 
forms and large almost giant mononuclear elements. There are also many 
large cells with single large nuclei and neutrophilic granules — the cellules 



804: 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



medullaires of Cornil — the myelocytes which are found in the "blood. Great 
numbers of polynuclear leucocytes are also present, as well as a certain 
number of small mononuclear elements. 

In the lymphatic forms of the disease there is a general lymphatic en- 
largement, which is usually associated with a certain amount of enlarge- 
ment of the spleen. In only one of my cases was the splenic enlargement 
notable. In the cases of lymphatic leukaemia the cervical, axillary, mesen- 
teric, and inguinal groups may be much enlarged, but the glands are usu- 
ally soft, isolated, and movable. They may vary considerably in size dur- 
ing the course of the disease. The tonsils and the lymph follicles of the 
tongue, pharynx, and mouth may be enlarged. Numerous mitoses may be 
found in the small cells of the lymphatic tissue. 

In some instances there are leukemic enlargements in the solitary and 
agminated glands of Peyer. In a case of Willcocks' there were growths 
on the surface of the stomach and gastro-splenic omentum. The thymus 
is rarely involved, though it has been enlarged in some of the cases of acute 
lymphatic leukaemia. The bone marrow in these cases may be replaced by 
a lymphoid tissue. Nucleated red corpuscles and the normal granular 
marrow elements may be greatly reduced in number. 

The liver may be enlarged, and in a case described by Welch it weighed 
over 13 pounds. The enlargement is usually due to a diffuse leukemic 
infiltration. The columns of liver cells are widely separated by leucocytes, 
which are partly within and partly outside the lobular capillaries. There 
may be definite leuksemic growths. 

There are rarely changes of importance in the lungs. The kidneys are 
often enlarged and pale, the capillaries may be distended with leucocytes, 
and leuksemic tumors may occur. The skin may be involved, as in a case 
described by Kaposi. 

Leukemic tumors in the organs are not common. They were present 
in only 1 of the 12 autopsies in my series. In 159 cases collected by Gowers 
there were only 13 instances of leukaemic nodules in the liver and 10 in 
the kidneys. These new growths probably develop from leucocytes which 
leave the capillaries. Bizzozero has shown that the cells which compose 
them are in active fission. 

Symptoms. — The onset is insidious, and, as a rule, the patient seeks 
advice for progressive enlargement of the abdomen and shortness of breath, 
or for the enlarged glands or the pallor, palpitation, and other symptoms 
of anaemia. Bleeding at the nose is common. Gastro-intestinal symptoms 
may precede the onset. Occasionally the first symptoms are of a very seri- 
ous nature. In one of the cases of my series the boy played lacrosse two 
days before the onset of the final haematemesis; and in another case a 
girl, who had, it was supposed, only a slight chlorosis, died of fatal haem- 
orrhage from the stomach before any suspicion had been aroused as to 
the true condition. 

Anaemia is not a necessary accompaniment of all stages of the disease; 
the subjects may look very healthy and well. 

As has been stated, the disease is most commonly seen in two main 
types, though combinations may occur. 



LEUKEMIA. 



805 



(1) Spleno-medullary Leukaemia. 

This is much the commonest type of the disease. The gradual in- 
crease in the volume of the spleen is the most prominent symptom in a 
majority of the cases. Pain and tenderness are common, though the pro- 
gressive enlargement may be painless. A creaking fremitus may be felt 
on palpation. The enlarged organ extends downward to the right, and 
may be felt just at the costal edge, or when large it may extend as far 
over as the navel. In many cases it occupies fully one half of the abdo- 
men, reaching to the pubes below and extending beyond the middle line. 
As a rule, the edge, in some the notch or notches, can be felt distinctly. 
Its size varies greatly from time to time. It may be perceptibly larger 
after meals. A haemorrhage or free diarrhoea may reduce the size. The 
pressure of the enlarged organ may cause distress after eating; in one case 
it caused fatal obstruction of the bowels. A murmur may sometimes be 
heard over the spleen, and Gerhardt has described a pulsation in it. 

The pulse is usually rapid, soft, compressible, but often full in volume. 
There are rarely any cardiac symptoms. The apex beat may be lifted an 
interspace by the enlarged spleen. Toward the close oedema may occur in 
the feet or general anasarca. Haemorrhage is common. There may be most 
extensive purpura, or hemorrhagic exudate into pleura or peritonaeum. 
Epistaxis is the most frequent form. Haemoptysis and hematuria are rare. 
Bleeding from the gums may be present. Haematemesis proved fatal in 
two of my cases, and in a third a large cerebral haemorrhage rapidly killed. 
The leukaemic retinitis is a part of the haemorrhagic manifestations. Sud- 
den death, without obvious cause, may occur, as in Bennett's first case. 

Local gangrene may develop, with signs of intense infection and high 
fever. There are very few pulmonary symptoms. The shortness of breath 
is due, as a rule, to the anaemia. Toward the end there may be oedema of 
the lungs, or pneumonia may carry off the patient. The gastro-intestinal 
symptoms are rarely absent. Nausea and vomiting are early features in 
some cases. Diarrhoea may be very troublesome, even fatal. Intestinal 
haemorrhage is not common. There may be a dysenteric process in the 
colon. Jaundice rarely occurs, though in one case of my series there were 
recurrent attacks. Ascites may be a prominent symptom, probably due to 
the presence of the splenic tumor. A leukaemic peritonitis also may be 
present, due to new growths in the membranes. 

The nervous system is not often involved. Facial paralysis has been 
noted. Headache, dizziness, and fainting spells are due to anaemia. The 
patients are usually tranquil. Coma may follow cerebral haemorrhage. 

The special senses are often affected. There is a peculiar retinitis, due 
chiefly to the extravasation of blood, but there may be aggregations of 
leucocytes, forming small leukaemic growths. Optic neuritis is rare. Deaf- 
ness has frequently been observed; it may appear early and possibly is due 
to haemorrhage. Features suggestive of Meniere's disease may come on 
quite suddenly, due to leukaemic infiltration or haemorrhage into the semi- 
circular canal. 

The urine presents no constant changes. The uric acid excreted is 
always in excess. 
50 



806 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



Priapism is a curious symptom which has been present in a large num- 
ber of cases. It may, as in one of our cases, be the first symptom. Pea- 
body reports a case in which it persisted for six weeks. The cause is not 
known. 

Fever was present in two thirds of my series. Periods of pyrexia may 
alternate with prolonged intervals of freedom. The temperature may 
range from 102° to 103°. 

Blood. — In all forms of the disease the diagnosis must be made by the 
examination of the blood, as it alone offers distinctive features. 

The most striking change in the more common form, the spleno-myelog- 
enous, is the increase in the colorless corpuscles. The average of my hos- 
pital cases was 298,700 per cubic millimetre, and the average ratio to the 
red cells was as 1 to 10. The proportion may be 1 to 5, or may even reach 
1 to 1. There are instances on record in which the number of leucocytes 
has exceeded that of the red corpuscles. The leucocytes may vary greatly 
within short intervals. 

The character of the cells in splenic myelogenous leukaemia is as fol- 
lows: The small mononuclear forms are little if at all increased; relatively 
they are greatly diminished. The eosinophiles are present in normal or 
increased relative proportion, so that there is a great total increase, and 
their presence is a striking feature in the stained blood-slide. The poly- 
nuclear neutrophiles may be in normal proportion; more frequently they 
are relatively diminished, and in the later stages they may form but a 
small proportion of the colorless elements. Marked differences in size be- 
tween individual polynuclear leucocytes may be noted; the same is true 
of the eosinophiles. The most characteristic features of the blood in this 
form of leukaemia is the presence of cells which do not occur in normal 
blood. They appear to be derived from the marrow, and are called by 
Ehrlich myelocytes. They are large mononuclear neutrophilic cells, which 
may vary much in size. They comprise about 30 per cent of the colorless 
cells. Nicked nuclei are common. Miiller has recently found many large 
mononuclear elements with karyokinetic figures in leukaemic blood and in 
the marrow. These probably correspond to the myelocytes of Ehrlich as 
well as to the " cellules medullaires " of Cornil. Polynuclear cells with 
coarse basophilic granules, " Mastzellen," are always present in this form 
of leukaemia in considerable numbers. The granules do not stain in Ehr- 
lich's triacid mixture, and the cells may be recognized as polynuclear non- 
granular elements. These cells, which form only about 0.28 per cent of 
the leucocytes of normal blood, may be even more numerous than the 
eosinophiles. 

Nucleated red blood-corpuscles are present in considerable numbers. 
These are usually " normoblasts," but cells with larger paler nuclei, some 
showing evidences of mitosis, may be seen. Eed cells with fragmented 
nuclei are common, while true megaloblasts may be found. The average 
number of red cells in my hospital series was 2,850,000 per cubic milli- 
metre. In no case was the count below two million. The average haemo- 
globin was 42 per cent. The accompanying blood chart is from a case of 
leukaemia with an enormously enlarged spleen. Among other points about 



LEUKAEMIA. 



807 



leukemic blood may be mentioned the feebleness of the amoeboid movement, 
as noted by Cafavy, which may be accounted for by the large number of 
mononuclear elements present, the polynuclear alone possessing this power. 
The blood-plates exist in variable numbers; they may be remarkably abun- 
dant. The fibrin network between the corpuscles is usually thick and 





1890. 


1891. 




SEPT. 


OCT. 


NOV. 


dec: 


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FEB. 


MAR. 


APR. 


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CORPUSCLES 



BLACK, RED CORPUSCLES. 



RED, HAEMOGLOBIN. 

Chart XX. — Leukaemia. 



BLUE, COLORLESS CORPUSCLES. 



dense. In blood-slides which arc kepi for a short time, Charcot's octohedral 
crystals separate, and in the blood of Leukaemia the haemoglobin shows a 
remarkable tendency to crystallize. 



808 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



2. Lymphatic Leukemia. 

This form of leukaemia is rare. There were 9 out of 26 in my hospital 
series. The superficial glands are usually most involved, but even when 
affected it is rare to see such large bunches as in Hodgkhr's disease. Ex- 
ternal lymph tumors are rare. Lymphatic leukaemia is often more rapid 
and fatal in its course, though chronic cases may occur. It is more com- 
mon in young subjects. 

The histological characters, of the blood in lymphatic leukaemia differ 
materially from those in the spleno-medullary form. The increase in the 
colorless elements is never so great as in the preceding form; a proportion 
of 1 to 10 would be extreme. The number of both white and red cells 
showed great variations in my series. The average haemoglobin percentage 
was 37, the red cells 2,294,000 and the white cells 144,800 per cubic milli- 
metre — a ratio of 1 to 16. This increase takes place solely in the lympho- 
cytes, all other forms of leucocytes being present in greatly diminished 
relative proportion. In one of my cases over 99 per cent of all the leuco- 
cytes were lymphocytes. In some cases, as Cabot has pointed out, this 
increase takes place largely in the smaller forms, while in others the large 
lymphocytes — cells nearly as large as polynuclear leucocytes — predominate. 
Eosinophiles and nucleated red corpuscles are rare. Myelocytes are not 
present. 

Combined forms of leukaemia are not common. One such instance oc- 
curred at the Johns Hopkins Hospital. Here the spleen, marrow, and 
lymphatic glands all showed marked changes. The blood in this instance 
showed, besides a large proportion of lymphocytes and myelocytes, a con- 
siderable number of large mononuclear leucocytes. 

Acute Leukcemia. — This is usually of the lymphatic type, and in young 
persons. Three of my cases ran a course of less than two months. They 
were all young. In this type the large lymphocytes are frequently present 
in considerable percentage. In the more chronic cases the small forms 
usually predominate. 

Diagnosis. — The recognition of leukaemia can be determined only 
by microscopical examination of the blood. The clinical features may be 
identical with those of ordinary splenic anaemia, or of Hodgkin's disease. 
An interesting question arises whether real increase in the leucocytes is 
the only criterion of the existence of the disease. Thus, for instance, in 
the case whose chart is given on page 807, the patient came under observa- 
tion in September, 1890, with 2,000,000 red blood-corpuscles per cubic mil- 
limetre, 30 per cent of haemoglobin, and 500,000 white blood-corpuscles per 
cubic millimetre — a proportion of 1 to 4. As shown by the chart, through- 
out September, October, November, and December, this ratio was main- 
tained. Early in January, under treatment with arsenic, the white cor- 
puscles began to decrease, and gradually, as shown in the chart, the normal 
ratio was reached. At this time could it be said that the case was one of 
leukaemia without increase in the number of leucocytes? The blood exam- 
ination showed that nucleated red corpuscles in large numbers as well as 
myelocytes, elements which are but rarely found in normal blood, were 
still present in numbers sufficient to suggest, if the patient had come under 



HODGKIN'S DISEASE. 



809 



observation for the first time, that leukaemia might occur. In another case 
the blood became perfectly normal and the spleen tumor disappeared twice 
in one year. A characteristic leukemic condition returned subsequently, 
with a fatal termination. An intercurrent infection usually causes a 
marked diminution in the number of leucocytes, which may even fall to 
normal. This is often seen in terminal infections. It is, however, not 
invariable, as in a recent case with streptococcus infection the leucocytes 
were unaltered until death. 

The remarkable " green cancer " or chloroma is, according to Dock, " a 
lymphomatous process similar in its classical features to leukaemia and 
pseudo-leukaemia." 

Prognosis. — Eecovery occasionally occurs. A great majority of the 
cases prove fatal within two or three years. Unfavorable signs are a tend- 
ency to haemorrhage, persistent diarrhoea, early dropsy, and high fever. 
Eemarkable variations are displayed in the course, and a transient im- 
provement may take place for weeks or even months. The pure lymphatic 
form seems to be of particular malignancy, some cases proving fatal in. 
from six to eight weeks; but there are exceptions, and I have recently seen 
a case in which the diagnosis was made ten years ago by W. H. Draper. 
The patient has had enlarged glands ever since, and, though not anaemic, 
the leucocytes were 242,000 per cubic millimetre, above 90 per cent of 
them being lymphocytes. The longest course of my hospital series of the 
lymphatic type was three years, and of the spleno-myelogenous about the 
same duration. 

Treatment.- — Fresh air, good diet, and abstention from mental worry 
and care, are the important general indications. The indicatio morbi can 
not be met. There are certain remedies which have an influence upon the 
disease. Of these, arsenic, given in large doses, is the best. I have re- 
peatedly seen improvement under its use. On the other hand, there are 
curious remissions in the disease, as mentioned above, which render thera- 
peutical deductions very fallacious. 

Quinine may be given in cases with a malarial history. Iron may be 
of value in some cases, as may also inhalations of oxygen. 

Excision of the leukaemic spleen has been performed 43 times, with 5 
recoveries (J. C. Warren). 

III. HODGKIN'S DISEASE. 

Definition. — An affection characterized by progressive hyperplasia of 
the lymph-glands, with anaemia, and occasionally the development of soe- 
ondary lymphoid growths in the liver, spleen, and other organs. The dis- 
ease has also the names' pseudo-leukcemia, general lymphadenoma, and aderpie. 

Hodgkin, the well-known morbid anatomist of Guy's Hospital, first 
described cases in detail, and by the labors of Wilks, Ynvliow, Billroth, 
and Cohnheim the disease attained definite recognition. 

Etiology. — A majority of the cases arc in young persons. In Powers' 
table of 100 cases, 30 were under twenty years, 34 between twenty and 
forty, and 36 above forty. Three fourths of the cases are in males. In a 



810 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



few instances heredity has been adduced as a possible cause, and antecedent 
disease, such as syphilis; but these are doubtful factors. More important 
is local irritation, upon which Trousseau lays special stress, and gives in- 
stances in which chronic irritation of the skin, chronic nasal catarrh, or the 
irritation of a decayed tooth gave rise to local gland swellings, which pre- 
ceded a general development of the disease. In a large majority of the 
cases the disease comes on insidiously, without any recognizable cause. 

Morbid Anatomy. — The Lymph-glands. — In a few cases the en- 
larged glands are hard and firm, but in a majority the growth is soft and 
elastic. In the early stage the individual glands are isolated, not larger 
than almonds or walnuts, and readily separated and movable. In more 
advanced stages the glands fuse together, and a group, as in the neck, may 
form a large tumor, the size of an orange or even of a cocoa-nut. About 
such masses the capsular tissues are hard and dense, forming a firm invest- 
ment. A growth may perforate the capsule and invade contiguous parts, 
such as the muscles, skin, or the solid organs. On section, the tumor has a 
grayish-white appearance; it is smooth, and of variable consistence, either 
firm and dry or soft and juicy. Suppuration is most frequently seen when 
the growth reaches the skin. In the deep glands the formation of pus is 
rare. Caseation is not common; occasionally there are areas of necrosis 
very like it. The superficial glands are most often attacked, particularly the 
cervical groups, and they may be traced as continuous chains along the 
trachea and the carotids, uniting the axillary and mediastinal glands. 

The axillary group is involved next in order of frequency, and the 
masses may pass beneath the pectorals and beneath the scapulas. The 
inguinal glands occasionally form very large masses. Of the internal 
groups, those of the thorax are most often affected, either the chain in the 
posterior mediastinum or the bronchial group, or those of the anterior 
mediastinum. The trachea and the aorta with its branches may be com- 
pletely surrounded by the growths, and be but little compressed. From 
the anterior mediastinum the masses may perforate the sternum and ap- 
pear as an external tumor. 

Of the abdominal groups, the retroperitoneal is most frequently in- 
volved and may form a continuous chain from the diaphragm to the in- 
guinal canals, arid extend into the pelvis. The glands may compress the 
ureters, involve the sacral or lumbar nerves, or impinge upon the iliac veins. 
Occasionally they adhere to the uterus and broad ligament so as to simu- 
late fibroids. I saw, some years ago, one of the most distinguished gynae- 
cologists of Germany perform laparotomy in a case of this kind, in which 
the diagnosis of myomatous tumors of the uterus had been made. Occa- 
sionally the mesenteric or hepatic lymph-glands may form large abdominal 
tumors. 

Histologically the chief change is an increase in the cells, with or with- 
out thickening of the reticulum. In the early stage there is simple hyper- 
plasia and the relations of the lymph paths are maintained, but when the 
glands are greatly enlarged the normal arrangement is disturbed. The 
reticulum varies extremely; in the softer growths it is expanded and can 
scarcely be found; in the harder structures the network of fibres is very 



HODGKIN'S DISEASE. 



811 



distinct, and there is probably an increased development of the adenoid 
tissue. 

Spleen. — In 75 per cent of the cases collected by Gowers this organ was 
hypertrophied, and in 56 of these it presented lymphoid growths. The en- 
largement is rarely great, and does not approximate to that of the large 
leukemic spleen. The lymphoid tumors form grayish-white bodies rang- 
ing in size from a pea to a walnut, and may resemble lymph-glands in ap- 
pearance and consistence. Histologically, they consist of lymph corpus- 
cles in a fibrous reticulum. 

The marrow of the long bones may be converted into a rich lymphoid 
tissue; in a few instances the pyoid form, such as is more common in leu- 
kaemia, has been found. The tonsils may be involved and the follicles at 
the root of the tongue. Occasionally secondary growths are seen in the 
intestines. 

The liver is often enlarged and may present scattered lymphoid tumors. 
The kidneys are occasionally involved and are the seat of growths similar 
to those in the spleen and liver. The lungs are occasionally directly at- 
tacked from the bronchial glands at the root, and secondary nodules may 
be found throughout their substance. Pleural effusions are not uncom- 
mon. Involvement of the nervous system is rare, but paraplegia may be 
induced by invasion of the spinal canal. The skin may be the seat of 
adenoid growths, as in a case reported by Greenfield. 

Symptoms. — Enlargement of the glands of the neck, axilla, or 
groins is usually the first symptom noticed. In a few cases the anaemia 
and constitutional symptoms attract attention before the glandular in- 
volvement is evident. When the trouble begins in the deeper groups, 
pressure effects may be first noticed; thus, paroxysmal dyspnoea with pain 
in the chest may result from enlargement of the bronchial glands before 
any physical signs can be detected. (Edema of the feet and shooting 
pains in the nerves were the first symptoms in one case which I dissected 
for Eoss, and in another case at the Montreal General Hospital there was 
paraplegia from pressure on the cord. Such instances, however, are ex- 
ceptional, and in the majority of cases the swelling of the superficial glands 
is the earliest symptom. Epistaxis has occasionally been noted, but not so 
frequently as in leukaemia. With progressive enlargement of the glands 
the patient becomes anaemic. 

Usually, the cervical group is first affected, and it may be impossible 
to decide whether the enlargement is syphilitic, tuberculous, or lymphad- 
enomatous. One side is first affected as a rule, and it may be months or 
even, as in one of my cases, three years before the affection extends to 
other groups. Ultimately huge tumors may develop, which obliterate the 
neck and extend upon the shoulders and over the clavicles and sternum. 
The trachea is surrounded, great dyspnoea is produced, and not infre- 
quently tracheotomy is necessary. In the later stages, the skin becomes 
involved and ulcerates. The axillary group may form large tumors, which 
compress the brachial or axillary veins and cause swelling of the arms. 
The inguinal glands may form large or even pendulous tumors. 

In the thoracic glands, as mentioned, the various groups may be in- 



812 DISEASES OP THE BLOOD AND DUCTLESS GLANDS. 



volved and produce pressure upon the veins or upon the trachea. In a 
case recently under observation the superior cava was completely obliter- 
ated and a very extensive collateral circulation was established by means 
of the mammary and epigastric veins. The skin over the sternum was a 
mass of fluctuating veins, some of which contained phleboliths. In the 
abdomen the mesenteric glands may be enlarged, or more commonly the 
retroperitoneal group. When the patient is thin there may be no difficulty 
in detecting these, but in stout persons the diagnosis may be impossible. 
In connection with the affections of the abdominal glands there may be 
bronzing of the skin, which was well marked in Case IV of my series. A 
remarkable feature is the variations in the rate of growth and in the size 
of the glands. They may reduce rapidly and almost disappear from a 
region, and before death the number of those visible may diminish very 
much. The spleen may be enlarged and readily palpable. The thyroid also 
may be involved, and in a few instances the thymus has been affected. 
Though present in a majority of the cases, there may be enormous enlarge- 
ment of the lymph-glands without marked anaemia. In one of my cases the 
blood-corpuscles did not sink below 4,000,000 per cubic millimetre, and in 
only one instance have I counted the blood below 2,000,000. The red blood- 
corpuscles rarely show extreme poikilocytosis. The white corpuscles may 
be moderately increased and the lymphocytes abundant, though usually 
there is little that is characteristic in the blood. Occasionally the leuco- 
cytes are greatly increased and the characters of the blood become those 
of a lymphatic leukaemia. Nucleated red blood-corpuscles may be present, 
but not in such numbers as in leukaemia. 

Of cardiac symptoms, palpitation is common. Haemic murmurs are 
often heard over the heart. Shortness of breath may be due to the anaemia, 
to pressure upon the trachea, or, in some instances, to pleuritic effusion 
associated with mediastinal growths. Fever is observed in nearly all cases; 
even in the early stages there is slight elevation. It may be of an irregu- 
lar hectic type, or continuous, with evening exacerbation. Very remark- 
able are the cases with ague-like paroxysms, which may persist for weeks 
or months. They were present in Case I of my series. Pel, of Amster- 
dam, has given a thorough description of these attacks, and Ebstein has 
described a case under the remarkable title of Chronic Eecurrent Fever, a 
New Infectious Disease. In his case during nine months the attacks were 
present for periods of from twelve to fourteen days and alternated with 
an apyrexia of ten or eleven days. 

The digestive symptoms are usually not marked. It is not uncommon 
to find albumin in the urine. Headache, giddiness, and noises in the ear 
may be associated with the anaemia. Delirium and coma may ensue. Deaf- 
ness may be produced by growth of the adenoid tissue in the phar}Tix close 
to the Eustachian tubes. Inequality of the pupils may be present, owing 
to pressure of the glands on the cervical sympathetic. The skin may show 
definite secondary lymphatic tumors, bronzing may occur, and occasionally 
a most intense and troublesome prurigo. 

Diagnosis. — A tuberculous adenitis may at first be very difficult to 
differentiate. The chief points of distinction are as follows: Tuberculous 



HODGKIN'S DISEASE. 



813 



adenitis is more common in the young and involves the submaxillary group 
of glands more frequently than those of the anterior and posterior cervical 
triangles, which are usually affected first in Hodgkin's disease. The en- 
largement may last for years in a group without extending. The bunches 
are often, when small, welded together and, most important of all, tend 
to suppurate — a feature rarely seen in true lymphadenoma, except when 
it has attained very large size. Strict limitation to one side of the neck 
or to the axilla is suggestive of tuberculous disease rather than lymphade- 
noma. 

There is an acute tuberculous adenitis, which may involve the lymph- 
glands of the neck, producing enormous enlargement. A man, aged twenty- 
four, was admitted to the General Hospital, Montreal, with great swelling 
of the cervical glands on both sides, tonsillitis, and sloughing pharyngitis, 
with irregular fever and diarrhoea. The case was at first regarded as one 
of Hodgkin's disease. The occurrence of rigors and intermittent pyrexia 
is in favor of lymphadenoma. There are cases in which it may for a time 
be impossible to make a diagnosis. When the glands are only moderately 
enlarged on one side of the neck or axilla, they should be removed, and the 
diagnosis can then be thoroughly established. 

Prognosis. — Eecovery is very rare. The course of the disease is ex- 
tremely variable. Early and rapid growth in the mediastinal groups may 
produce pressure effects and cause death before the development is ex- 
treme. In some cases the enlargements spread rapidly and group after 
group becomes involved in a few months. These acute case may run a 
course in three or four months. Chronic cases may last for three or four 
years. Periods of quiescence are not uncommon. The tumors may not 
only cease to grow, but gradually diminish and even disappear, without 
special treatment. Usually a cachexia develops, the anaemia progresses, 
and there are dropsical symptoms. The mode of death is usually by 
asthenia; less commonly by pressure from a tumor; and occasionally in 
coma. 

Treatment. — When small and localized the glands should be re- 
moved. Local applications are of doubtful benefit. I have never seen 
special improvement follow the persistent use of iodine or the various 
ointments. 

Arsenic has a positive value in the disease. It should be given in in- 
creasing doses, and stopped when unpleasant effects are manifested. The 
results have in many instances been striking. Due allowance must be 
made for the fluctuations in the size of the growths which occur sponta- 
neously. Ill effects from the administration of Fowlers solution, even 
for months at a time, arc rare, but I have had a case in which neuritis 
followed the use of § iv 3 jfTlxviij within a period of less than three months. 
Eecoveries have been reported under this treatment. Personally, no in- 
stance of recovery has come under my notice in tin 1 cases of which I have 
notes. Phosphorus is recommended by Gowers and Broadbent, and should 
be used if the arsenic is not well borne. Quinine, iron, and eod-liver oil 
are useful as tonics. Every possible means must be taken to support the 
patient's strength. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



IV. PURPURA. 

Strictly speaking, purpura is a symptom, not a disease; but under this 
term are conveniently arranged a number of affections characterized by 
extravasations of the blood into the skin. In the present state of our 
knowledge a satisfactory classification cannot be made. Excluding symp- 
tomatic purpura, W. Koch groups all forms, including haemophilia, under 
the designation hemorrhagic diathesis, believing that intermediate forms 
link the mild purpura simplex and the most intense purpura haemorrhagica; 
while F. A. Hoffmann considers them all (except haemophilia) under the 
heading morbus maculosus. The purpuric spots vary from 1 to 3 or 4 mm. 
in diameter. When small and pin-point-like they are called petechia; 
when large, they are known as ecchymoses. At first bright red in color, 
they become darker, and gradually fade to brownish stains. They do not 
disappear on pressure. 

In all cases of purpura the coagulation time of the blood should be esti- 
mated (Wright); the coagulometer is a useful clinical instrument for the 
purpose. Normal blood clots in the tubes in from three to five minutes. In 
some forms of purpura the coagulation time is retarded to ten or fifteen 
minutes, and in haemophilia it has been delayed to fifty minutes. 

The following is a provisional grouping of the cases: 

Symptomatic Purpura. — (a) Infectious. — In pyaemia, septicaemia, 
and malignant endocarditis (particularly in the last affection), ecchymoses 
may be very abundant. In typhus fever the rash is always purpuric. 
Measles, scarlet fever, and more particularly small-pox, have each a variety 
characterized by an extensive purpuric rash. 

(b) Toxic. — The virus of snakes produces with great rapidity extrava- 
sation of blood — a condition which has been very carefully studied by 
Weir Mitchell. Certain medicines, particularly copaiba, quinine, bella- 
donna, mercury, ergot, and the iodides occasionally, are followed by a 
petechial rash. Purpura may follow the use of comparatively small doses 
of iodide of potassium. It is not a very common occurrence, considering 
the great frequency with which the drug is employed. A fatal event may 
be caused by a small amount, as in a case reported by Stephen Mackenzie 
of a child which died after a dose of grains. An erythema may precede 
the haemorrhage. It is not always a simple purpura, but may be an acute 
febrile eruption of great intensity. In September, 1894, a man aged forty- 
eight was admitted under my care with arterio-sclerosis and dropsy. The 
latter yielded rapidly to digitalis and diuretin. When convalescent he was 
ordered iodide of potassium in 10-grain doses three times a day, and took 
in fourteen days 420 grains. He had high fever, coryza, swelling of the 
throat, and the most extensive purpura over the whole body. Under this 
division, too, comes the purpura so often associated with jaundice. 

(c) Cachectic. — Under this heading are best described the instances of 
purpura which develop in the constitutional disturbance of cancer, tuber- 
culosis, Hodgkin's disease, Bright's disease, scurvy, and in the debility of 
old age. In these cases the spots are usually confined to the extremities. 



PURPURA. 



815 



They may be very abundant on the lower limbs and about the wrists 
and hands. This constitutes, probably, the commonest variety of the 
disease, and many examples of it can be seen in the wards of any large 
hospital. 

(cl) Neurotic. — One variety is met with in cases of organic disease. It 
is the so-called myelopathic purpura, which is seen occasionally in loco- 
motor ataxia, particularly following attacks of the lightning pains and, 
as a rule, involving the area of the skin in which the pains have been most 
intense. Cases have been met with also in acute myelitis and in transverse 
myelitis, and occasionally in severe neuralgia. Another form is the re- 
markable hysterical condition in which stigmata, or bleeding points, appear 
upon the skin. 

(e) Mechanical. — This variety is most frequently seen in venous stasis 
of any form, as in the paroxysms of whooping-cough and in epilepsy. 

Arthritic. — This form is characterized by involvement of the joints. 
It is usually known, therefore, as rheumatic, though in reality the evidence 
upon which this view is based is not conclusive. Of 200 cases of purpura 
analyzed by Stephen Mackenzie, 61 had a history of rheumatism. For the 
present it seems more satisfactory to use the designation arthritic. Three 
groups of cases may be recognized: 

(a) A mild form, often known as Purpura simplex, seen most com- 
monly in children, in whom, with or without articular pain, a crop of 
purpuric spots appears upon the legs, less commonly upon the trunk and 
arms. As pointed out by Graves, this form is not infrequently associated 
with diarrhoea. The disease is seldom severe. There may be loss of ap- 
petite, and slight anaemia. Fever is not, as a rule, present, and the pa- 
tients get well in a week or ten days. These cases are usually regarded 
as rheumatic, and are certainly associated, in some instances, with un- 
doubted rheumatic manifestations; yet in a majority of the patients which 
I have seen the arthritis was slighter than in the ordinary rheumatism of 
children, and no other manifestations were present. 

(b) Purpura (Peliosis) rheumatica (Schdnlein's Disease). — This remark- 
able affection is characterized by multiple arthritis, and an eruption 
which varies greatly in character, sometimes purpuric, more commonly 
associated with urticaria or with erythema cxudativum. The disease is most 
common in males between the ages of twenty and thirty. It not infre- 
quently sets in with sore throat, a fever from 101° to 103°, and articular 
pains. The rash, which makes its appearance first on the Legs or about the 
affected joints, may be a simple purpura or may show ordinary urticarial 
wheals. In other instances there are nodular infiltrations, not to be distin- 
guished from erythema nodosum. The combination of wheals and purpura, 
the purpura urticans, is very distinctive. Much more rarely vesication is 
met with, the so-called pemphigoid purpura. The amount of oedema is vari- 
able; occasionally it is excessive. In one ease, which 1 saw in Montreal 
with Molson, the chin and lower lip were enormously swollen, tense, glazed, 
and deeply ecchymotic. The eyelids were swollen and purpuric, while 
scattered over the cheeks and about the joints were numerous spots of 
purpura urticans. These are the cases which have been described as febrile 



816 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



purpuric oedema. The temperature range, in mild cases, is not high, but 
may reach 102° or 103°. 

The urine is sometimes reduced in amount and may be albuminous. 
The joint affections are usually slight, though associated with much pain, 
particularly as the rash comes out. Eelapses may occur and the disease 
may return at the same time for several years in succession. 

The diagnosis of Schonlein^s disease offers no difficulty. The associa- 
tion of multiple arthritis with purpura and urticaria is very characteristic. 
In a case which I saw with Musser there was endo-pericarditis, and the 
question at first arose whether the patient had malignant endocarditis 
with extensive cutaneous infarcts. 

Schonlein's peliosis is thought by most writers to be of rheumatic 
origin, and certainly many of the cases have the characters of ordinary 
rheumatic fever, plus purpura. By many, however, it is regarded as a 
special affection, of which the arthritis is a manifestation analogous to 
that which occurs in haemophilia and in scurvy. The frequency with 
which sore throat precedes the attack, and the occasional occurrence of en- 
docarditis or pericarditis, are certainly very suggestive of true rheumatism. 

The cases usually do well, and a fatal event is extremely rare. The 
throat symptoms may persist and give trouble. In two instances I have 
seen necrosis and sloughing of a portion of the uvula. 

(c) Henoch's Purpura. — This variety, seen chiefly in children, is char- 
acterized by (1) relapses or recurrences, often extending over several years; 
(2) cutaneous lesions, which are those of erythema multiforme rather than 
of simple purpura; (3) gastro-intestinal crises — pain, vomiting, and diar- 
rhoea; (4) joint pains or swelling, often trifling; (5) haemorrhages from 
the mucous membranes. When from the kidney, an intense haemorrhagic 
nephritis may supervene, which proved fatal, with the symptoms of acute 
Bright's disease, in one of my cases, and became chronic in a case under 
D. W. Prentiss. Any one or two of the above symptoms may be absent; the 
intestinal crises with enlargement of the spleen may be present and recur 
for months before the true nature of the trouble becomes manifest. This 
form has an interesting connection with the angio-neurotic oedema, which 
is also characterized by severe gastro-intestinal crises. The prognosis is, as 
a rule, good. I have reported a series of 18 cases.* 

Purpura Hsemorrhagica. — Under this heading may be consid- 
ered the cases of very severe purpura with haemorrhages from the mucous 
membranes. The affection, known as the morbus maculosus of Werlhof, 
is most commonly met with in young and delicate individuals, particu- 
larly in girls; but cases are described in which the disease has attacked 
adults in full vigor. After a few days of weakness and debility, purpuric 
spots appear on the skin and rapidly increase in numbers and size. Bleed- 
ing from the mucous surfaces sets in, and the epistaxis, haematuria, and 
haemoptysis may cause profound anaemia. Chart XXI illustrates the rapid- 
ity with which anaemia is produced and the gradual recovery. Death may 
take place from loss of blood, or from haemorrhage into the brain. Slight 



* Jacobi, Festschrift, 1900. 



PURPURA. 



817 



fever usually accompanies the disease. In favorable cases the affection 
terminates in from ten days to two weeks. There are instances of purpura 
haemorrhagica of great malignancy, which may prove fatal within twenty- 
four hours — purpura fulminans. This form is most commonly met with 
in children, and is characterized by cutaneous haemorrhages, which develop 
with great rapidity. Death may occur before any bleeding takes place 
from the mucous membranes. 

In the diagnosis of purpura haemorrhagica it is important to exclude 
scurvy, which may be done by the consideration of the previous health,. 



no* 
100* 

90* 
80* 
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APRIL. . 


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14,000 














































































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CORPUSCLES 



BLACK, RED CORPUSCLES* 



RED, HAEMAGLOBIN, 



BLUE, COLORLESS C0RPUSCLE9. 



Chart XXI. — Illustrates the rapidity with which anaemia is produced in purpuri 
haemorrhagica and the gradual recovery. 



the circumstances under which the disease develops, and by the absence 
of swelling of the gums. The malignant forms of tin 4 fevers, particularly 
small-pox and measles, are distinguished by the prodromes and the higher 
temperature. 

Treatment. — In symptomatic purpura attention should be paid to 
the conditions under which it develops, and measures should be employed 
to increase the strength and to restore a normal blood condition. Tonics, 
good food, and fresh air meet these indications. In the simple purpura of 



818 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



children, or that associated with slight articular trouble, arsenic in full 
doses should be given. No good is obtained from the small doses, but the 
Fowler's solution should be pushed freely until physiological effects are 
obtained. In peliosis rheumatica the sodium salicylates may be given, but 
with discretion. I confess not to have seen any special control of the haem- 
orrhages by this remedy. 

Aromatic sulphuric acid, ergot, turpentine, acetate of lead, or tannic 
and gallic acids, may be used, and in some instances they seem to check 
the bleeding. Oil of turpentine is perhaps the best remedy, in 10 or 15 
minims doses three or four times a day. Wright, of Netley, advises the 
use of calcium chloride in 20-grain doses four times a day (for three or 
four clays) to increase the coagulability of the blood. In bleeding from 
the mouth, gums, and nose, the inhalation of carbon dioxide, irrigations 
with 2-per-cent gelatin solution, and the application of an aqueous solution 
of suprarenal extract should be tried. The last remedy has often acted 
promptly. 

HEMORRHAGIC DISEASES OF THE NEW-BORN. 

1. Syphilis Hemorrhagica Neonatorum. — The child may be born 
healthy, or there may be signs of haemorrhage at birth. Then in a few 
days there are extensive cutaneous extravasations and bleeding from the 
mucous surfaces and from the navel. The child may become deeply jaun- 
diced. The post mortem shows numerous extravasations in the internal 
organs and extensive syphilitic changes in the liver and other organs. 

2. Epidemic Hemoglobinuria (Winckel's Disease). — Haemoglobinuria in 
the new-born, which occasionally develops in epidemic form in lying-in 
institutions, is a very fatal affection, which sets in usually about the fourth 
day of life. The child becomes jaundiced, and there are marked gastro- 
intestinal symptoms, with fever, jaundice, rapid respiration, and sometimes 
cyanosis. The urine contains albumin and blood-coloring matter — me- 
thaemoglobin. The disease has to be distinguished from the simple icterus 
neonatorum, with which there may sometimes be blood or blood-coloring 
matter in the urine. The post mortem shows an absence of any septic 
condition of the umbilical vessels, but the spleen is swollen, and there are 
punctiform haemorrhages in different parts. Some cases have shown in 
a marked degree acute fatty degeneration of the internal organs — the so- 
called Buhl's disease. 

3. Morbus Maculosus Neonatorum. — Apart from the common visceral 
haemorrhages, the result of injuries at birth, bleeding from one or more 
of the surfaces is a not uncommon event in the new-born, particularly in 
hospital practice. Forty-five cases occurred in 6,700 deliveries (C. W. 
Townsend). The bleeding may be from the navel alone, but more com- 
monly it is general. Of Townsend's 50 cases, in 20 the blood came from 
the bowels (melcena neonatorum), in 14 from the stomach, in 14 from the 
mouth, in 12 from the nose, in 18 from the navel, in 3 from the navel 
alone. The bleeding begins within the first week, but in rare instances 
is delayed to the second or third. Thirty-one of the cases died and 19 
recovered. The disease is usually of brief duration, death occurring in 
from one to seven days. The temperature is often elevated. The nature 



HAEMOPHILIA. 



819 



of the disease is unknown. As a rule, nothing abnormal is found post 
mortem. The general and not local nature of the affection, its self -limited 
character, the presence of fever, and the greater prevalence of the disease 
in hospitals, suggest an infectious origin (Townsend). The bleeding may 
be associated with intense hematogenous jaundice. Not every case of 
bleeding from the stomach or bowels belongs in this category. Ulcers of 
the oesophagus, stomach, and duodenum have been found in the new-born 
dead of melcena neonatorum. The child may draw the blood from the breast 
and subsequently vomit it. In the treatment the external warmth must be 
maintained, and in feeble infants the couveuse may be used. Camphor is 
recommended, ergotin hypodermically, and the suprarenal extract. 

V. HEMOPHILIA, 

Definition. — A constitutional fault, hereditary or acquired, charac- 
terized by a tendency to uncontrollable bleeding, either spontaneous or 
from slight wounds, sometimes associated with a form of arthritis. The 
coagulation time of the blood is usually much retarded. 

The fact that fatal haemorrhage might occur from slight, trifling wounds 
had been known for centuries. Fordyce, in 1781, recognized the hereditary 
nature, and early in the last century described the American bleeder fami- 
lies. Buel, Otto, Hay, Coates, and others in this country published similar 
reports. The disease is considered at length in the monographs of Legg 
and Grandidier, and recently by Stempel. 

Etiology. — In a majority of cases the disposition is hereditary. In 
the Appleton-Swain family, of Reading, Mass., there have been cases for 
nearly two centuries; and F. F. Brown, of that town, tells me that in- 
stances have already occurred in the seventh generation. Atavism through 
the female alone is almost the rule, and the daughters of a bleeder, though 
healthy and free from any tendency, are almost certain to transmit the 
disposition to the male offspring. The affection is much more common 
in males than in females — 11:1, Legg; 4:1, Stempel. The tendency usually 
appears within the first two years of life. It is rare for manifestations to 
be delayed until the tenth or twelfth year. Families in all conditions of 
life are affected. The bleeder families are usually large. The members 
are healthy-looking, and have fine, soft skins. The Anglo-German races 
are chiefly attacked; of 209 cases collected within the ten years 1890-1900 
by Stempel, 96 were German, 95 English or American, only 16 French, 
Hungarian, or Russian. Steiner has reported from my clinic instances oc- 
curring in a negro family. 

Morbid Anatomy. — No special peculiarities have been described. 
In some instances changes have been found in the smaller vessels; but 
in others careful studies have been negative. An unusual dimness of the 
vessels has been noted. Haemorrhages have been Pound in and about the 
capsules of the joints, and in a few instances inflammation of I lie synovial 
surfaces. The nature of the disease is unknown. An increase in the num- 
ber of the red blood-corpuscles — orvthrooytlucmia — with a peculiar frailty 
of the blood-vessels, has been supposed. A deficiency of the leucocytes and 



820 DISEASES OP THE BLOOD AND DUCTLESS GLANDS. 



a diminution of the blood-plates have been noted, though in a case from my 
clinic, studied by Steiner, these structures were normal. Wright has found 
the coagulation time much retarded, as long as twenty-three and forty-five 
minutes. 

Symptoms. — Usually haemophilia is not noted in the child until a 
trifling cut is followed by serious or uncontrollable haemorrhage, or spon- 
taneous bleeding occurs and presents insuperable difficulties in its arrest. 
The symptoms may be grouped under three divisions: external bleedings, 
spontaneous and traumatic; interstitial bleedings, petechias and ecchy- 
moses; and the joint affections. The external bleedings may be spon- 
taneous, but more commonly they follow cuts and wounds. In 334 cases 
(Grandidier) the chief bleedings were epistaxis, 169; from the mouth, 43; 
stomach, 15; bowels, 36; urethra, 16; lungs, 17; and in a few instances 
bleeding from the skin of the head, the tongue, finger-tips, tear-papilla, 
eyelids, external ear, vulva, navel, and scrotum. 

Traumatic bleeding may result from blows, cuts, scratches, etc., and 
the blood may be diffused into the tissues or discharged externally. Trivial 
operations have proved fatal, such as the extraction of teeth, circumcision, 
or venesection. It is possible that there may be local defects which make 
bleeding from certain parts of the body more dangerous. D. Hayes Agnew 
mentioned to me the case of a bleeder who had always bled from cuts and 
bruises above the neck, never from those below. The bleeding is a capil- 
lary oozing. It may last for hours, or even many days. Epistaxis may 
prove fatal in twenty-four hours. In the slow bleeding from the mucous 
surfaces large blood tumors may form and project from the nose or mouth, 
forming remarkable-looking structures, and showing that the blood has 
the power of coagulation. The interstitial haemorrhages may be spon- 
taneous, or may result from injury. Petechias or large extravasations — 
haematomata — may occur, the latter usually following blows. 

Joint Affections. — The knees and elbows are chiefly involved, but the 
small joints may be attacked. The onset is usually acute, with slight fever 
and swelling and pain, and sometimes redness. In other instances there is 
haemorrhagie effusion without fever. Konig recognizes three stages: first, 
haemarthrosis; secondly, an inflammatory process, with fever and spindle- 
formed swelling, which is apt to be mistaken for tuberculosis; and, lastly, 
there may be extensive organic changes, which may even resemble those 
of arthritis deformans. 

Diagnosis. — In the diagnosis of the condition the family tendency 
is important. A single uncontrollable haemorrhage in child or adult is not 
to be ranked as haemophilia; but it is only when a person shows a marked 
tendency to multiply haemorrhages, spontaneous or traumatic, which tend- 
ency is not transitor} r but persists, and particularly if there have been joint 
affections, that we may consider the condition haemophilia. Such condi- 
tions as epistaxis, recurring for years — if no other haemorrhage occurs — 
or recurring haematuria from one kidney, which has been spoken of as 
unilateral renal haemophilia, have no association with the true disease. 
Peliosis rheumatica is an affection which touches haemophilia very closely, 
particularly in the relation of the joint swellings. It may also show itself 



SCURVY. 



821 



in several members of a family. The diagnosis from the various forms 
of purpura is usually easy. 

Prognosis. — The patients rarely die in the first bleeding. The 
younger the individual the worse is the outlook, though children rarely die 
in the first year. Grandidier states that of 152 boy subjects, 81 died before 
the termination of the seventh year. The longer the bleeder survives the 
greater the chance of his outliving the tendency; but it may persist to 
old age, as shown in the case of Oliver Appleton, the first reported Ameri- 
can bleeder, who died at an advanced age of haemorrhage from a bed-sore 
and from the urethra. The prognosis is graver in a boy than in a girl. 
In the latter menstruation is sometimes early and excessive, but fortunately, 
in the female members of hemophilic families, neither this function nor 
the act of parturition brings with it special dangers. 

Treatment. — Members of a bleeder's family, particularly the boys, 
should be guarded from injury, and operations of all sorts should be 
avoided. The daughters should not marry, as it is through them that the 
tendency is propagated. 

When an injury or wound has occurred, absolute rest and compression 
should first be tried, and if these fail the styptics may be used. In epis- 
taxis ice, tannic and gallic acid may be tried before resorting to plug- 
ging. Internally ergot seems to have done good in several cases. Legg 
advises the perchloride of iron in half-drachm doses every two hours with 
a purge of sulphate of soda. For the epistaxis the inhalation of carbon 
dioxide through the nostrils is recommended by A. E. Wright. He also 
advises a solution of fibrin ferment and chloride of calcium as a styptic. 
Dried suprarenal gland, 1 part to 10 of water, freshly prepared, may be 
applied to the part, or the active principle, epinephrin or adrenalin, may 
be tried. Gelatin in 5-per-cent solution is warmly recommended. Vene- 
section has been tried in several cases. Transfusion has been employed, 
but without success. During convalescence, iron and arsenic should be 
freely used. 

VI. SCURVY (Scorbutus). 

Definition. — A constitutional disease characterized by great debility, 
with anaemia, a spongy condition of the gums, and a tendency to haemor- 
rhages. 

Etiology. — The disease has been known from the earliest times, and 
has prevailed particularly in armies in the field and among sailors on long 
voyages. It has been well called "the calamity of sailors." 

From the early part of the last century, owing largely to the efforts 
of Lind and to a knowledge of the conditions upon which the disease de- 
pends, scurvy has gradually disappeared from the naval service. In the 
mercantile marine, cases still occasionally occur, owing to the lack of proper 
and suitable food. 

In parts of Russia scurvy is endemic, at certain seasons reaching epi- 
demic proportions; and the leading authorities upon the disorder, now in 



822 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



that country, are almost unanimous, according to Hoffmann,* in regard- 
ing it as infectious. 

In the United States scurvy has become a very rare disease. To the 
hospitals in the seaport towns sailors are now and then admitted with it. 
In large almshouses outbreaks occasionally occur. A very great increase 
of foreign population of a low grade has in certain districts made the dis- 
ease not at all uncommon. In the mining districts of Pennsylvania the 
Hungarian, Bohemian, and Italian settlers are not infrequently attacked. 
McGrew has recently reported 42 cases in Chicago, limited entirely to 
Poles. He ascertained that in a large proportion of the cases the diet was 
composed of bread, strong coffee, and meat. Occasionally one meets with 
scurvy among quite well-to-do people. One of the most characteristic cases 
I have ever seen was in a woman with chronic dyspepsia, who had lived 
for many months chiefly on tea and bread. Some years ago scurvy was 
not infrequent in the large lumbering camps in the Ottawa Valley. Judg- 
ing from the Eeport of the American Pediatric Society, we must infer that 
infantile scurvy is on the increase in this country. In Great Britain and 
Ireland it has become very rare; only 302 cases were admitted to the Sea- 
man's Hospital in the twenty-two years ending 1896 (Johnson Smith). 

There are three theories of the disease: 

(a) That it is the result of an absence of those ingredients in the food 
which are supplied by fresh vegetables. What these constituents are has 
not yet been definitely determined. Garrod holds that the defect is in the 
absence of the potassic salts. Others believe that the essential factor is 
the absence of the organic salts present in fruits and vegetables. Ealfe, 
who has made a very careful study of the subject, believes that the absence 
from the food of the malates, citrates, and lactates reduces the alkalinity 
of the blood, which depends upon the carbonate directly derived from 
these salts. 

(b) That it is due to toxic materials in the foods — some unknown 
organic poison the product of decomposition. That it is not due to an 
absence of fresh vegetables or the salts of fruits and vegetables seems to 
have been settled by Nansen and his comrades, who, living for months under 
the most unfavorable hygienic surroundings, but eating fresh bear's meat 
and bear's blood, escaped scurvy. The experiments of Vaughan, Harley, 
and Jackson, who have produced a disease analogous to scurvy by feeding 
monkeys on slightly tainted meat, with maize and rice, support this view. 

(c) In opposition to these chemical views it is urged that the disease 
depends upon a specific (as yet unknown) micro-organism. 

Other factors play an important part in the disease, particularly phys- 
ical and moral influences — overcrowding, dwelling in cold, damp quarters, 
and prolonged fatigue under depressing influences, as during the retreat 
of an army. Among prisoners, mental depression plays an important role. 
It is stated that epidemics of the disease have broken out in the French 
convict-ships en route to New Caledonia even when the diet was amply 



* Lehrbuch der Constitutionskrankheiten, F. A. Hoffmann (1893), a work to which the 
student is referred for the best exposition of this group of disorders. 



SCURVY. 



823 



sufficient. Nostalgia is sometimes an important element. It is an inter- 
esting fact that prolonged starvation in itself does not necessarily cause 
scurvy. Not one of the professional fasters of late years has displayed any 
scorbutic symptom. The disease attacks all ages, but the old are more 
susceptible to it. Sex has no special influence, but during the siege of 
Paris it was noted that the males attacked were greatly in excess of the 
females. 

Morbid Anatomy. — The anatomical changes are marked, though 
by no means specific, and are chiefly those associated with haemorrhage. 
The blood is dark and fluid. The microscopical alterations are those of a 
severe anaemia, without leucocytosis. The bacteriological examination has 
not yielded anything very positive. Practically there are no changes in 
the blood, either anatomical or chemical, which can be regarded as pecul- 
iar to the disease. The skin shows the ecchymoses evident during life. 
There are haemorrhages into the muscles, and occasionally about or even 
into the joints. Haemorrhages occur in the internal organs, particularly 
on the serous membranes and in the kidneys and bladder. The gums are 
swollen and sometimes ulcerated, so that in advanced cases the teeth are 
loose and have even fallen out. Ulcers are occasionally met 'with in the 
ileum and colon. Haemorrhages into the mucous membranes are extremely 
common. The spleen is enlarged and soft. Parenchymatous changes are 
constant in the liver, kidneys, and heart. 

Symptoms. — The disease is insidious in its onset. Early symptoms 
are loss in weight, progressively developing weakness, and pallor. Very 
soon the gums are noticed to be swollen and spongy, to bleed easily, and 
in extreme cases to present a fungous appearance. These changes, re- 
garded as characteristic, are sometimes absent. The teeth may become 
loose and even fall out. Actual necrosis of the jaw is not common. The 
breath is excessively foul. The tongue is swollen, but may be red and 
not much furred. The salivary glands are occasionally enlarged. Haem- 
orrhages beneath the mucous membranes of the mouth are common. The 
skin becomes dry and rough, and ecchymoses soon appear, first on the legs 
and then on the arms and trunk, and particularly into and about the hair- 
follicles. They are petechial, but may become larger, and when subcu- 
taneous may cause distinct swellings. In severe cases, particularly in the 
legs, there may be effusion between the periosteum and the bone, forming 
irregular nodes, which, in the case of a sailor from a whaling vessel who 
came under my observation, had broken down and formed foul-looking 
sores. The slightest bruise or injury causes haemorrhages into the injured 
part. (Edema about the ankles is common. The " scurvy sclerosis," seen 
oftenest in the legs, is a remarkable infiltration of the subcutaneous tissues 
and muscles, forming a brawny induration, the skin over which may be 
blood-stained. Haemorrhages from the mucous membranes are less con- 
stant symptoms; epistaxis is, however, frequent. Haemoptysis and haeinate- 
mesis are uncommon. Haematuria and bleeding from, the bowels may be 
present in very severe cases. 

Palpitation of the heart and feebleness and irregularity of the impulse 
are prominent symptoms. A haemic murmur can usually be heard at the 



824 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



base. Hemorrhagic infarction of the lungs and spleen has been described. 
Eespiratory symptoms are not common. The appetite is impaired, and 
owing to the soreness of the gums the patient is unable to chew the food. 
Constipation is more frequent than diarrhoea. Pain, tenderness, or swell- 
ing in the joints were present in 13 of McGrew's 42 cases. The urine is 
often albuminous. The changes in its composition are not constant; the 
specific gravity is high; the color is deeper. The statements with reference 
to the inorganic constituents are contradictory. Some authorities have 
found the phosphates and potassium salts to be deficient; others hold that 
they are increased. 

There are mental depression, indifference, in some cases headache, and 
in the later stages delirium. Cases of convulsions, of hemiplegia, and of 
meningeal haemorrhage have been described. Kemarkable ocular symp- 
toms are occasionally met with, such as night-blindness or day-blindness. 

In advanced cases necrosis of the bones may occur, and in young per- 
sons even separation of the epiphyses. There are instances in which the 
cartilages have separated from the sternum. The callus of a recently 
repaired fracture has been known to undergo destruction. Fever is not 
present, except in the later stages, or when secondary inflammations in the 
internal organs appear. The temperature may, indeed, be sometimes below 
normal. Acute arthritis is an occasional complication. 

Diagnosis. — No difficulty is met in the recognition of scurvy when 
a number of persons are affected together. In isolated cases, however, the 
disease is distinguished with difficulty from certain forms of purpura. The 
association with manifest insufficiency in diet, and the rapid ameliora- 
tion with suitable food, are points by which the diagnosis can be readily 
settled. 

Prognosis. — The outlook is good, unless the disease is far advanced 
and the conditions persist which lead to its development. The mortality 
now is rarely great. Death results from gradual heart-failure, occasionally 
from sudden syncope. Meningeal haemorrhage, extravasation into the 
serous cavities, entero-colitis, and other intercurrent affections may prove 
fatal. 

Prophylaxis. — The regulations of the Board of Trade require that a 
sufficient supply of antiscorbutic articles of diet be taken on each ship; so 
that now, except as the result of accident, the occurrence of scurvy is rare 
in sailors. 

Treatment. — The juice of two or three lemons daily and a diet of 
plenty of meat and fresh vegetables suffice to cure all cases of scurvy, 
unless far advanced. When the stomach is much disordered, small quan- 
tities of scraped meat and milk should be given at short intervals, and the 
lemon-juice in gradually increasing quantities. A bitter tonic, or a steel and 
bark mixture, may be given. As the patient gains in strength, the diet may 
be more liberal, and he may eat freely of potatoes, cabbage, water-cresses, 
and lettuce. The stomatitis is the symptom which causes the greatest dis- 
tress. The permanganate of potash or dilute carbolic acid forms the best 
mouth-wash. Pencilling the swollen gums with a tolerably strong solution 
of nitrate of silver is very useful. The solution is better than the solid stick, 



SCURVY. 



825 



■as it reaches to the crevices between the granulations. The constipation 
which is so common is best treated with large enemata. For other con- 
ditions, snch as haemorrhages and ulcerations, suitable measures must be 
employed. 

INFANTILE SCURVY {Barlow's Disease). 

As in adults, scurvy may occur in children in consequence of imper- 
fect food supply. 

W. B. Cheadle and Gee, in London, have described in very young chil- 
dren a cachexia associated with haemorrhage. Cheadle regarded the cases 
as scurvy ingrafted on a rickety stock. Gee called his cases periosteal 
cachexia. Cases had previously been regarded as acute rickets. 

A few years later Barlow made an exhaustive study of the condition 
with careful anatomical observations. The affection is now recognized as 
infantile scurvy, and in Germany is called Barlow's Disease. The Ameri- 
can Pediatric Society has collected (1898) in this country 379 cases. Of 
these, the hygienic surroundings were good in 303. A majority of the 
patients were under twelve months. The proprietary foods, particularly 
malted milk and condensed milk, seem to be the most important factors in 
producing the disease. There are instances in which it has developed in 
breast-fed infants, and in others fed on the carefully prepared milk of the 
IValker-Gordon laboratories. 

The following is a general clinical summary, taken from Barlow's Brad- 
shaw Lecture, 1894: 

" So long as it is left alone the child is tolerably quiet; the lower limbs 
are kept drawn up and still; but when placed in its bath or otherwise 
moved there is continuous crying, and it soon becomes clear that the pain 
is connected with the lower limbs. At this period the upper limbs may 
be touched with impunity, but any attempt to move the legs or thighs 
gives rise to screams. Next, some obscure swelling may be detected, first 
on one lower limb, then on the other, though it is not absolutely symmet- 
rical. . . . The swelling is ill-defined, but is suggestive of thickening 
round the shafts of the bones, beginning above the epiphyseal junctions. 
Gradually the bulk of the limbs affected becomes visibly increased. . . . 
The position of the limbs becomes somewhat different from what it was at 
the outset. Instead of being flexed they lie everted and immobile, in a 
state of pseudo-paralysis. . . . About this time, if not before, great weak- 
ness of the back becomes manifest. A little swelling of one or both scap- 
ulae may appear, and the upper limbs may show changes. These are rarely 
so considerable as the alterations in the lower limbs. There may be swell- 
ing above the wrists, extending for a short distance up the forearm, and 
some swelling in the neighborhood of the epiphyses of the humerus. There 
is symmetry of lesions, but it is not absolute; and the limb affection is 
generally consecutive, though the involvement of one limb follows very 
close upon another. The joints are free. In severe cases another symp- 
tom may now be found — namely, crepitus in the regions adjacent to the 
junctions of the shafts with the epiphyses. The upper and lower extremi- 
ties of the femur, and the upper extremity of the tibia, are the common 
51 



826 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



sites of such fractures; but the upper end of the humerus may also be sc* 
affected. ... A very startling appearance may be observed at this period 
in the front of the chest. The sternum, with the adjacent costal carti- 
lages and a small portion of the contiguous ribs, seems to have sunk bodily 
back, en bloc, as though it had been subjected to some violence which had 
fractured several ribs in the front and driven them back. Occasionally 
thickenings of varying extent may be found on the exterior of the vault 
of the skull, or even on some of the bones of the face. . . . Here also must 
be mentioned a remarkable eye phenomenon. There develops a rather 
sudden proptosis of one eyeball, with pumness and very slight staining of 
the upper lid. Within a day or two the other eye presents similar appear- 
ances, though they may be of less severity. The ocular conjunctiva may 
show a little ecchymosis, or may be quite free. With respect to the con- 
stitutional symptoms accompanying the above series of events the most 
important feature is the profound anaemia which is developed. . . . The 
anaemia is proportional to the amount of limb involvement. As the case- 
proceeds, there is a certain earthy-colored or sallow tint, which is note- 
worthy "in severe cases, and when once this is established bruise-like ecchy- 
moses may appear, and more rarely small purpura?. Emaciation is not a. 
marked feature, but asthenia is extreme and suggestive of muscular failure. 
The temperature is very erratic; it is often raised for a day or two, when 
successive limbs are involved, especially during the tense stage, but is- 
rarely above 101° or 102°. At other times it may be normal or subnormal." 
If the teeth have appeared the gums may be spongy. 

The condition must always be looked for in young children with diffi- 
culty in moving the lower limbs, or in whom paralysis is suspected. What 
is known sometimes as Parrot's disease, or syphilitic pseudo-paralysis, may 
be confounded with it. In it the loss of motion is more or less sudden in 
the upper or lower limbs, or in both, due to a solution of continuity and 
separation of the cartilage at the end of the diaphysis. There are usually 
crepitation and much pain on movement. 

The essential lesion is a subperiosteal blood extravasation, which causes 
the thickening and tenderness in the shafts of the bones. In some in- 
stances there is haemorrhage in the intramuscular tissue. 

The prophylaxis is most important. The various proprietary forms of 
condensed milk and preserved foods for infants should not be used. The 
fresh cow's milk should be substituted, and a teaspoonful of meat-juice 
or gravy may be given with a little mashed potato. Orange-juice or lemon- 
juice should be given three or four times a day.- Recovery is usually prompt 
and satisfactory. 



VII. STATUS LYMPH ATI CUS. LYMPH ATI SM. 

Much attention has been paid lately to a somewhat rare condition met 
with chiefly in children and young persons, in which the lymphatic glands 
and lymph tissues throughout the body, the spleen, the thymus, and the 
lymphoid bone marrow are in a state of hyperplasia. These features have 



STATUS LYMPHATICUS. LYMPHATISM. 



827 



been found associated with rickets and with hypoplasia of the heart and 
aorta. The special interest lies in the fact that these pathological condi- 
tions have been met with frequently in cases of sudden death. Paltauf 
and others of the Vienna school, who have written extensively on the sub- 
ject, believe that individuals with this hyperplasia have lowered powers 
of resistance, and are particularly liable to paralysis of the heart. The 
condition has not received much attention in England and in this coun- 
try. An excellent account of it, by James Ewing, appeared in the New 
York Medical Journal of July 10, 1897. 

Anatomical Condition. — (a) Lymph-glands. — The pharyngeal, thoracic, 
and abdominal groups are most frequently affected. The cervical, axil- 
lary, and inguinal are less commonly involved, but these glands may show 
slight enlargement. The lymphatic structures of the alimentary tract, the 
tissues of the tonsils, the adenoid structures in the upper pharynx, and 
the solitary and agminated follicles Of the small and large intestines are 
usually much enlarged. The hyperplasia of the intestinal lymphatic struc- 
tures may be the most remarkable, the individual glands standing out like 
peas. 

(b) Spleen. — Enlargement of this organ is usually moderate in degree. 
The Malpighian bodies may show very prominently, and when anaemic may 
look like large tubercles. The organ is usually soft and hypersemic. 

(c) The thymus is enlarged, and may measure as much as 10 cm. in 
length. It looks swollen and soft, and on section may exude a milky white 
fluid. 

(d) The lone marrow has been found in a state of hyperplasia, and the 
yellow marrow of the long bones in young adults, and even in persons 
between the ages of twenty and thirty, has been found replaced by red 
marrow. Among other associated conditions of this constitutio lymphatica, 
as it has been called, are hypoplasia of the heart and aorta and enlargement 
of the thyroid gland. In a large number of the cases in children rickets is 
coincident. 

The diagnosis of the lymphatic constitution is not always easy. En- 
largement of the superficial glands, with hypertrophy of the tonsils, signs 
of slight swelling of the thyroid, dulness over the sternum, with signs of 
enlargement of the mesenteric glands, are among the most important fea- 
tures. Signs of hypoplasia of the vascular system are still more uncertain, 
though Quincke believes that in such instances the left ventricle is dilated 
and the peripheral arteries may be much smaller than normal. The sub- 
jects are usually ill-developed and infantile in conformation. 

Sudden Death in the status lymphaticus. — What has directed the at- 
tention of writers more particularly to this condition is the frequency with 
which it has been found in cases of unexpected death from very trifling 
and inadequate causes. A good deal of attention was directed to the sub- 
ject by the death of the son of Professor Langerhans, of Berlin, immedi- 
ately after the preventive inoculation with the antitoxine of diphtheria. 
In another child death occurred under similar circumstances. The condi- 
tion has also been met with in a number of cases of sudden death under 
anaesthetics, and I know of one instance during anaesthesia for adenoid 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



growths. Cases of sudden death of persons in the water, who have fallen 
in and, though immediately recovered, were dead, or who have died sud- 
denly while bathing, are referred by Paltauf to this condition. And, lastly, 
there is the large group of cases of sudden death in children without recog- 
nizable cause, in whom post mortem the thymus has been found enlarged — 
the so-called "Thymus Tod" (see under Thymus Gland). It has also 
been suggested that certain of the sudden deaths during convalescence 
from the infectious fevers are to be referred to this status lymphaticus. 
Escherich thinks that certain measures usually harmless, such as hydro- 
therapy, may have an untoward effect in children in this condition of lym- 
phatism, and adds that tetany and laryngismus may be associated with it. 

The whole question is one which deserves the most careful study. The 
anatomical features appear fairly well defined. The clinical features are 
by no means so clear, nor is it at all certain in what way sudden death is 
caused in these cases. The students of the question have, however, in the 
past few years brought forward evidence enough to show that the subjects 
of this lymphatic constitution have a diminished vital resistance, and are 
especially prone to fatal collapse under ordinarily very inadequate exciting 
causes. 

VIII. DISEASES OF THE SUPRARENAL BODIES. 

1. Addison's Disease. 

Definition. — A constitutional affection characterized by asthenia, de- 
pressed circulation, irritability of the stomach, and pigmentation of the 
skin. Tuberculosis of the adrenals is the common anatomical change. 
Eecent observations indicate that the symptoms are due to loss of function 
of the suprarenal bodies. 

The recognition of the disease is due to Addison, of Guy's Hospital, 
whose monograph on The Constitutional and Local Effects of Disease of 
the Suprarenal Capsules was published in 1855. 

Etiology. — Males are more frequently attacked than females. In 
Greenhow's analysis of 183 cases 119 were males and 64 females. A ma- 
jority of the cases occur between the twentieth and the fortieth year. A 
congenital case has been described in which the skin had a yellow-gray 
tint. The child lived for eight weeks, and post mortem the adrenals were 
found to be large and cystic. Injury such as a blow upon the abdomen 
or back, and caries of the spine, have in many cases preceded the attack. 
The* disease is rare in America. The number of deaths during the census 
year 1890 was 99 — 59 males and 40 females. Twelve cases have come 
under my personal observation, 9 in men. One case was in a negro. 

Morbid Anatomy and Pathology.— There is rarely emaciation 
or anoemia. Eolleston * thus summarizes the condition of the suprarenal 
bodies in Addison's disease: 



* Goulstonian Lectures, Royal College of Physicians, British Medical Journal, 1895, 
i, to which the student is referred for an exhaustive consideration of the entire question. 



DISEASES OF THE SUPRARENAL BODIES. 



829 



" 1. The fibro-caseous lesion due to tuberculosis — far the commonest 
condition found. 2. Simple atrophy. 3. Chronic interstitial inflamma- 
tion leading to atrophy. 4. Malignant disease invading the capsules, in- 
cluding Addison's case of malignant nodule compressing the suprarenal 
vein. 5. Blood extravasated into the suprarenal bodies. 6. Xo lesion of 
the suprarenal bodies themselves, but pressure or inflammation involving 
the semilunar ganglia. 

" The first is the only common cause of Addison's disease. The others, 
with the exception of simple atrophy, may be considered as very rare." 

Among other anatomical features the condition of the abdominal sym- 
pathetic has been specially studied. The nerve-cells of the semilunar 
ganglia have been described as degenerated and deeply pigmented, 
and the nerves sclerotic. The ganglia are not uncommonly entangled in 
the cicatricial tissue about the adrenals. The spleen has occasionally 
been found enlarged; the thymus may have persisted and be larger than 
normal. 

It is difficult to explain satisfactorily all the symptoms of this remark- 
able disease. The two chief theories which have been advanced are briefly 
as follows: (a) That the disease depended upon the loss of function of 
the adrenals. This was the view of Addison. The balance of experimental 
evidence is in favor of the view that the adrenals are functional glands, 
which furnish an internal secretion essential to the normal metabolism. 
Schafer and Oliver have shown that the human adrenals contain a very 
powerful extract, which is not to be obtained in cases of Addison's dis- 
ease; they have also studied the toxic effects on animals of the extracts of 
the glands. In the cases in which the adrenals have been found involved 
without the symptoms of Addison's disease, accessory glands may have 
been present; while in the rare cases in which the symptoms of the disease 
have been present with healthy adrenals the semilunar ganglia and adjacent 
tissues have been involved in dense adhesions, which may have interfered 
readily with the vessels or lymphatics of the glands. On this view Addi- 
son's disease is due to an inadequate supply of the adrenal secretion, just 
as myxcedema is caused by loss of function of the thyroid gland. " Whether 
the deficiency in this internal secretion leads to a toxic condition of the 
blood or to a general atony and apathy is a question which must remain 
open " (Rolleston). (b) That it is an affection of the abdominal sympa- 
thetic system, induced most commonly by disease of the adrenals, but also 
by other chronic disorders which involve the solar plexus and its ganglia. 
According to this view, it is an affection of the nervous system, and the 
pigmentation has its origin in changes induced through the trophic nerves. 
The pronounced debility is the outcome of disturbed tissue metabolism, 
and the circulatory, respiratory, and digestive symptoms are due to im- 
plication of the pncumogastric. The changes found in the abdominal 
sympathetic are held to support this view, and its advocates urge the occur- 
rence of pigmentation of the skin in tuberculosis of the peritonaeum, cancer 
of the pancreas, or aneurism of the abdominal aorta. Bra m well thinks 
that the symptoms may be in part due to irritation of the sjmipathetic and 
in part to adrenal inadequacy. 



830 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



Symptoms. — In the words of Addison, the characteristic symptoms 
are " anaemia, general languor or debility, remarkable feebleness of the 
heart's action, irritability of the stomach, and a peculiar change of color 
in the skin." 

The onset is, as a rule, insidious. The feelings of weakness, as a rule, 
precede the pigmentation. In other instances the gastro-intestinal symp- 
toms, the weakness, and the pigmentation come on together. There are 
a few cases in the literature in which the whole process has been acute, 
following a shock or some special depression. There are three important 
symptoms of the disease: 

(1) Pigmentation of the Shin. — This, as a rule, first attracts the atten- 
tion of the patient's friends. The grade of coloration ranges from a light 
yellow to a deep brown, or even black. In typical cases it is diffuse, but 
always deeper on the exposed parts and in the regions where the normal 
pigmentation is more intense, as the areolae of the nipples and about the 
genitals; also wherever the skin is compressed or irritated, as by the waist- 
band. At first it may be confined to the face and hands. Occasionally it 
is absent. Patches showing atrophy of pigment, leucoderma, may occur. 
The pigmentation is found on the mucous membranes of the mouth, con- 
junctivae, and vagina. Pigmentation of the mucous membrane is not dis- 
tinctive. It has been found in chronic stomach troubles, etc. (Fr. Schultze), 
and is common in the negro. A patchy pigmentation of the serous mem- 
branes has often been found. Over the diffusely pigmented skin there 
may be little mole-like spots of deeper pigmentation. 

(2) Gastro-intestinal Symptoms. — The disease may set in with attacks 
of nausea and vomiting, spontaneous in character. Toward the close there 
may be pain with retraction of the abdomen, and even features suggestive 
of peritonitis (Ebstein). A marked anorexia may be present. The gas- 
tric symptoms are variable throughout the course; occasionally they are 
absent. Attacks of diarrhoea are frequent and come on without obvious 
cause. 

(3) Asthenia. — This is perhaps the most characteristic feature of the 
disease. It may be manifested early as a feeling of inability to carry on 
the ordinary occupation, and the patient complains constantly of feeling 
tired. The weakness is specially marked in the muscular and cardio- 
vascular systems. There may be an extreme degree of muscular prostra- 
tion in an individual apparently well nourished and whose muscles feel 
firm and hard. The cardio-vascular asthenia is manifest in a feeble, irregu- 
lar action of the heart, which may come on in paroxysms, in attacks of 
vertigo, or of syncope, in one of which the disease may prove fatal. Head- 
ache is a frequent symptom; convulsions occasionally occur. McMunn 
has described an increase in the urinary pigments, and a pigment has been 
isolated of very much the same character as the melanin of the skin. 

Anaemia was a symptom specially referred to by Addison, but it has 
been present -in a marked degree in only one of my cases. I saw an in- 
stance, in Philadelphia, with J. C. Wilson, in which the diagnosis at first 
was not at all clear between Addison's disease and pernicious anaemia. 

The mode of termination is either by syncope, which may occur even 



DISEASES OF THE SUPRARENAL BODIES. 



831 



-early in the disease, by gradual progressive asthenia, or by the development 
of tuberculous lesions. In two cases I have known a noisy delirium with 
urgent dyspnoea to precede the fatal event. 

Diagnosis. — Pigmentation of the skin is not confined to Addison's 
disease. The following are the conditions which may give rise to an in- 
crease in the pigment: 

(1) Abdominal growths — tubercle, cancer, or lymphoma. In tubercu- 
losis of the peritonaeum pigmentation is not uncommon. 

(2) Pregnancy, in which the discoloration is usually limited to the face, 
the so-called masque des femmes enceintes. Uterine disease is a common 
•cause of a patchy melasma. 

(3) Hcemochromatosis, associated with hypertrophic cirrhosis, pigmenta- 
tion of the skin, and diabetes. More commonly in overworked persons of 
constipated habit and with sluggish livers there is a patchy staining about 
the face and forehead. 

(4) The vagabond's discoloration, caused by the irritation of lice and 
-dirt, which may reach a very high grade, and has sometimes been mis- 
taken for Addison's disease. 

(5) In rare instances there is deep discoloration of the skin in mela- 
notic cancer, so deep and general that it has been confounded with melasma 
suprarenale. 

(6) In certain cases of exophthalmic goitre abnormal pigmentation 
occurs, as noted by Drummond and others. 

(7) In a few rare instances the pigmentation common in scleroderma 
may be general and deep. 

(8) In the face there may be an extraordinary degree of pigmentation 
•due to innumerable small black comedones. If not seen in a very good 
light, the face may suggest argyria. Pigmentation of an advanced grade 
may occur in chronic ulcer of the stomach and in dilatation of the organ. 

(9) Argyria could scarcely be mistaken, and yet I was consulted in a 
case in which the diagnosis of Addison's disease had been made by several 
good observers. 

(10) Arsenic when taken for many months may cause a most intense 
pigmentation of the skin. 

(11) Lastly, with arterio-sclerosis and chronic heart-disease there may 
be marked melanoderma. 

In any case of unusual pigmentation these various conditions must be 
sought for; the diagnosis of Addison's disease is scarcely justifiable with- 
out the asthenia. In many instances it is difficult early in the disease to 
arrive at a definite conclusion. The occurrence of fainting fits, of nausea, 
and gastric irritability are important indications. As the lesion of the 
capsules is almost always tuberculous, in doubtful cases the tuberculin 
test may be used. In a recent case, a robust, healthy-looking man with 
symptoms of Addison's disease, the characteristic reaction was obtained. 

Prognosis. — The disease is usually fatal. The cases in which the 
bronzing is slight or does not occur run a more rapid course. There are 
occasionally acute cases which, with great weakness, vomiting, and diar- 
rhoea, prove fatal in a few weeks. In a few cases the disease is much pro- 



832 



DISEASES OP THE BLOOD AND DUCTLESS GLANDS. 



longed, even to six or ten years. In rare instances recovery has taken place, 
and periods of improvement, lasting many months, may occur. 

Treatment.— The causal indications cannot be met. When there is 
profound asthenia the patient should be confined to bed, as fatal syncope 
may at any time occur. In three of my cases death was sudden. When 
anaemia is present iron may be given in full doses. Arsenic and strychnia 
are useful tonics. For the diarrhoea large doses of bismuth should be 
given; for the irritability of the stomach, creasote, hydrocyanic acid, ice, 
and champagne. The diet should be light and nutritious. Many patients 
thrive best on a strict milk diet. 

Treatment by Suprarenal Extract. — Following the researches of Schafer 
and Oliver, the latter used the gland in the treatment of the disease. Kinni- 
cutt has collected 48 cases treated with adrenal preparations. Of these,, 
6 were reported as cured and 22 as improved. I have used it in a number 
of cases within the past five years. One patient was greatly benefited, 
gained 19 pounds, the symptoms of asthenia disappeared, and he was alive 
two years subsequently, but was still pigmented. The other cases were 
not benefited in the slightest degree. The gland may be given raw or par- 
tially cooked or in a glycerin extract. Tabloids of the dried extract are 
used, one grain of which corresponds to fifteen of the gland. Three of the 
tabloids may be given daily. Operation has been suggested, but has not 
been carried out on any undoubted case. 

2. Othee Diseases of the Supkakenal Capsules. 

Haemorrhage into the gland is not uncommon, particularly in new-born 
children (Spencer). Tuberculosis may occur without the symptoms of Ad- 
dison's disease. Among 157 cases of tuberculous disease in various parts 
of the body, caseous tuberculous foci were found in 20 in the suprarenale 
without signs of Addison's disease (Kolleston). 

Tumors of the Suprarenals. — Adenomata are common, particularly the 
small yellowish nodules. Fibromata and fatty tumors occur, but are rare. 

Of malignant growths secondary tumors are not uncommon. In 63 cases 
of secondary carcinoma, in 7 the suprarenal bodies were the seat of growths 
(Eolleston). Of the primary growths, both sarcoma and carcinoma may 
occur. Affleck and Leith have collected 20 cases of primary sarcoma. 
Ramsay informs me that we have had 3 cases of primary tumor of the 
suprarenals at the J ohns Hopkins Hospital — 2 in females and 1 in a male. 
Two were sarcomata and 1 a carcinoma. The diagnosis in all was malig- 
nant tumor of the kidney. The cases were operated upon, 1 with com- 
plete recovery. 

IX. DISEASES OF THE SPLEEN.* 

Apart from the acute swelling in fever, the chronic enlargement of the 
organ in paludism, leukaemia, cirrhosis of the liver, and heart-disease, we 

* For a good discussion of the general pathology of the spleen, see Rolleston in 
Allbutt's System of Medicine. 



DISEASES OF THE SPLEEN. 



833 



see very few instances of disease of the spleen. These affections have been 
fully described, but there remain several conditions to which brief reference 
may be made. 

1. Movable Spleen. 

Movable or wandering spleen is seen most frequently in women the 
subjects of enteroptosis. It is occasionally met with without signs of dis- 
placement of other organs. It may be found accidentally in individuals 
who present no symptoms whatever. In other cases there are dragging, 
uneasy feelings in the back and side. All grades are met with, from a 
spleen that can be felt completely below the margin of the ribs to a condi- 
tion in which the tumor-mass impinges upon the pelvis; indeed, the organ 
has been found in an inguinal hernia! In the large majority of all cases the 
spleen is enlarged. Sometimes it appears that the enlargement has caused 
relaxation of the ligaments; in other instances the relaxation seems con- 
genital, as movable spleens have been found in different members of the 
same family. Possibly traumatism may account for some of the cases. 
Apart from the dragging, uneasy sensations and the worry in nervous pa- 
tients, wandering spleen causes very few serious symptoms. Torsion of 
the pedicle may produce a very alarming and serious condition, leading 
to great swelling of the organ, high fever, or even to necrosis. A young 
woman was admitted to my colleague Kelly's ward with a tumor supposed 
to be ovarian, but which proved to be a wandering, moderately enlarged 
spleen. She was transferred to the medical ward, where she developed 
suddenly very great pain in the abdomen, a large swelling in the left flank, 
and much tenderness. Halsted operated and found an enormously enlarged 
spleen in a condition of necrosis, adherent to the adjacent parts and to 
the abdominal wall. He laid it open freely, and large necrotic masses of 
spleen tissue discharged for some time. She made a good recovery. 

The diagnosis of a wandering spleen is usually easy unless the organ 
becomes fixed and is deformed by adhesions and perisplenitis. The shape 
of the organ and the sharp margin with the notches are the points to be 
specially noted. 

The treatment of the condition is important. Occasionally the organ 
may be kept in position by a properly adapted belt and a pad under the left 
costal margin. Kemoval of the displaced organ has been advised and car- 
ried out in many cases, and nowadays it is not a very serious operation. It 
is, however, as a rule unnecessary. In 2 cases of enlarged spleen under my 
care, with great mobility, causing much discomfort and uneasiness, Halsted 
completely relieved the condition by replacing the spleen, packing it in 
position with gauze, and allowing firm adhesions to take place. Both these 
patients were seen more than eighteen months after the operation and the 
organ had remained in position. 

2. PiUPTURE OF THE SPLEEN. 

This is of interest medically in connection with the spontaneous rup- 
ture in cases of acute enlargement during typhoid fever or malaria. The 
condition seems very rare in this country. We have had instances of rup- 



834 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



ture of a malarial spleen following a blow, but neither in this disease nor 
in typhoid have we had an instance of spontaneous rupture. In India and 
in Mauritius rupture of the spleen is stated to be very common. Fatal 
haemorrhage may follow puncture of a swollen spleen with a hypodermic 
needle. Occasionally the rupture results from the breaking of an infarct 
or of an abscess. The symptoms are those of haemorrhage into the peri- 
tonaeum, and the condition demands immediate laparotomy. 

3. Infarct and Abscess of the Spleen. 

Emboli in the splenic arteries causing infarcts may be either infective 
or simple. They are seen most frequently in ulcerative endocarditis and 
in septic conditions. Infarcts may also follow the formation of thrombi 
in the branches of the splenic artery in cases of fever. They are not very 
infrequent in typhoid. In a few instances the infarcts have followed 
thrombosis in the splenic veins. They are chiefly of pathological interest. 
The infarct of the spleen may be suspected in cases of septicaemia or pyae- 
mia when there is pain in the splenic region, tenderness on pressure, and 
slight swelling of the organ; on several occasions I have heard a well-marked 
peritoneal friction rub. Occasionally in the infective infarcts large ab- 
scesses are formed, and in rare instances the whole organ may be converted 
into a sac of pus. 

Tumors of the spleen, hydatid and other cysts of the organ, and gummata 
are rare conditions of anatomical interest, for an account of which the 
reader is referred to Eollestoms article and to the section on the spleen, 
by G-. E. Lockwood, in Loomis and Thompson's System of Medicine. 

4. Splenic Anaemia. 

Under this head are grouped cases characterized by idiopathic enlarge- 
ment of the spleen with anaemia. "Whether the anaemia is secondary to the 
splenic condition or both are secondary to some unknown cause we do not 
know. Perhaps several different conditions are classed together under the 
term. Attention was first called to it in this country by H. C. Wood, in 
1871. Formerly regarded as the splenic form of Hodgkhr's disease, it is 
generally now held to be separate from it. It is sometimes termed primitive 
splenomegaly. To a group with enlarged spleen and cirrhosis of the liver 
Banti has drawn special attention. Pathologically the spleen shows atrophy 
and sclerosis of the Malpighian corpuscles. The majority of the cases are 
in adult males. The main symptoms are enlargement of the spleen, an 
anaemia of a secondary type without leucocytosis, haemorrhages in some 
cases, and usually a gradual downward course. The spleen is greatly en- 
larged, reaching often to the navel. In some cases this enlargement seems 
to have preceded the anaemia. Haemorrhages from the stomach occurred 
in many of my cases, usually at intervals of some months. Several patients 
also passed blood by the bowels. In some they were almost lethal, and in 
one case after splenectomy death followed a profuse haematemesis. The 
autopsy showed oesophageal varices. Ascites may occur even without 



DISEASES OF THE THYROID GLAND. 



835 



cirrhosis of the liver. The lymphatic glands are not specially enlarged. 
The blood condition is that of a secondary anaemia. Many of the patients 
do not present the objective features of a severe anaemia. The average 
number of red corpuscles in my series has been over three millions per cubic 
millimetre. The haemoglobin is relatively low. The leucocytes are usually 
diminished in number. The differential count shows no special features. 
There is frequently marked pigmentation of the skin. As the disease ad- 
vances there is emaciation and progressive asthenia. S. West, in Allbutt's 
System, has described three stages. The duration is variable. It has been 
given as from six months to three years, but the majority of my cases 
have had a much longer course. Many of them had existed over five years, 
and one probably for twelve years. Several of my patients were in good 
health even after a duration of some years, with the exception of the recur- 
ring haemorrhages, for which they sought relief. 

The diagnosis has to be made from splenic leukaemia, Hodgkin's disease 
with an enlarged spleen, cirrhosis of the liver, either alcoholic, syphilitic, 
or hypertrophic, with an enlarged spleen, and old cases of malaria with 
the same condition. It is not likely to be mistaken for pernicious anaemia, 
although three cases in my wards showed features of both conditions. They 
had an enlarged spleen, the blood picture of pernicious anaemia, and a 
long duration. The blood features and associated conditions may serve to 
prevent error. 

The treatment must be that of anaemia generally. Splenectomy has been 
successful in some instances. Warren gives 20 recoveries among 25 cases 
of operation. One out of three cases operated on from my wards recov- 
ered and is well three years after. The ultimate outlook, apart from 
operation, is not hopeful, although the course is not always progressively 
downward. 

X. DISEASES OF THE THYROID GLAND. 

1. GrOITRE. 

Definition. — Hypertrophy of the thyroid gland, occurring sporad- 
ically or endemically. 

In this country sporadic cases are common. The endemic centres re- 
ferred to in Barton's monograph (1810) and in Hirsch's Geographical 
Pathology no longer exist. The disease is very prevalent about the eastern 
end of Lake Ontario, and in parts of Michigan (Dock). Endemically it 
is found particularly in the mountainous regions of Switzerland and in 
parts of Italy. No satisfactory explanation has been given of the existence 
of the disease in this form. 

Anatomically the following varieties may be distinguished: (a) Paren- 
chymatous, in which the enlargement is general and the follicles, usually 
newly formed, contain a gelatinous colloid material, (b) Vascular, in 
which the enlargement is chiefly due to dilatation of the blood-vessels 
without the new formation of glandular tissue, (c) Cystic goitre, in which 
the enlarged gland is occupied by large cysts, the walls of which often 
undergo calcification. 



836 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



Symptoms. — The enlargement may be uniform throughout the en- 
tire gland, or affect only one lobe, or the isthmus alone. When small, a 
goitre causes no inconvenience. In its growth it may compress the trachea, 
causing dyspnoea, or may pass beneath the sternum and compress the veins. 
These, however, are exceptional circumstances, , and in a large proportion 
of all cases no serious symptoms are noted. The affection usually comes 
under the care of the surgeon. Sudden death occasionally occurs in large 
bronchoceles. In some instances it may be difficult to determine the cause, 
and it has been thought to be associated with pressure on the vagi. I have 
reported an instance in which it resulted from haemorrhage into the gland 
and into the adjacent tissues. The blood passed into the" cellular tissues; 
of the neck and under the sternum, covering the aorta and pericardium. 
In regions in which goitre prevails the drinking-water should be boiled. 
Change of locality is sometimes followed by cure. The medicinal treat- 
ment is very unsatisfactory. Iodine and various counterirritants exter- 
nally, iodide of potash, ergot, and many other drugs are recommended by 
writers. The thyroid extract has been used with success by Bruns in 9 
of 12 cases. 

2. TlJMOES OF THE THYEOID. 

These are very varied, (a) Adenomata, either simple or malignant. 
The latter may form extensive metastases. A case is reported by Hay- 
ward in which growths resembling thyroid tissue occurred in the lungs and 
various bones of the body, (b) Cancer, of which several forms have been 
described, (c) Sarcoma. All of these have a surgical rather than a medi- 
cal interest. 

It may be mentioned that the aberrant or accessory thyroid gland may 
form large tumors in the mediastinum or in the pleura. Cases have been 
reported by F. A. Packard and myself, and an instance is on record in 
which an enormous cystic accessory thyroid occupied the entire right 
pleura. 

Lingual goitre occasionally develops at the base of the tongue, and is 
an enlarged accessory thyroid in that situation. It may lead to difficult deg- 
lutition and interference with articulation. 

Thyroid abscess is rare. In Havel's monograph on Strumitis (1892) 
cases are given after nearly every one of the specific diseases, and he re- 
ports 18 cases from Ivocher's clinic, nearly all secondary or metastatic. 

3. Exophthalmic Goitee (Parry's Disease). 

Definition. — A disease characterized by exophthalmos, enlargement 
of the thyroid, and functional disturbance of the vascular system. It is 
very possibly caused by disturbed function of the thyroid gland (hyper- 
thyroidism). 

Historical Note. — In the posthumous writings of Caleb Hillier Parry 

(1825) is a description of 8 cases of Enlargement of the Thyroid G-land 
in Connection with Enlargement or Palpitation of the Heart, In the first 
case, seen in 1786, he also describes the exophthalmos: " The eyes were pro- 



DISEASES OF THE THYROID GLAND. 



837 



traded from their sockets, and the countenance exhibited an appearance 
of agitation and distress, especially in any muscular movement/' The 
Italians claim that Flajani described the disease in 1800. I have not been 
.able to see his original account, but Moebius states that it is meagre and 
inaccurate, and bears no comparison with that of Parry. If the name of 
any physician is to be associated with the disease, undoubtedly it should 
be that of the distinguished old Bath physician. Graves described the dis- 
ease in 1835 and Basedow in 1840. 

Etiology. — The disease is more frequent in women than in men. Of 
200 cases tabulated by Eshner, there were 161 females. The age of onset 
is usually from the twentieth to the thirtieth year. It is sometimes seen in 
several members of the same family. Worry, ' fright, and depressing emo- 
tions precede the development of the disease in a number of cases. 

The disease is regarded by some as a pure neurosis, in favor of which is 
urged the onset after a profound emotion, the absence of lesions, and the 
■cure which has followed in a few cases after operations upon the nose. Others 
believe that it is caused by a central lesion in the medulla oblongata. In 
support of this there is a certain amount of experimental evidence, and in 
-a few autopsies changes have been found in the medulla. Of late years 
the view has been urged, particularly by Moebius and by Greenfield, that 
exophthalmic goitre is primarily a disease of the thyroid gland (hyper- 
thyrea), in antithesis to myxcedema (athyrea). The clinical contrast be- 
tween these two diseases is most suggestive — the increased excitability of 
the nervous system, the flushed, moist skin, the vascular erythism in the 
one; the dull apathy, the low temperature, slow pulse, and dry skin of the 
other. The changes in the gland in exophthalmic goitre are, as shown by 
Greenfield, those of an organ in active evolution — viz., increased prolifera- 
tion, with the production of newly formed tubular spaces and absorption 
of the colloid material which is replaced by a more mucinous fluid (Brad- 
shaw Lecture, 1893). The thyroid extract given in excess produces symp- 
toms not unlike those of Parry's disease — tachycardia, tremor, headache, 
sweating, and prostration. Beclere has recently reported a case in which 
exophthalmos developed after an overdose. Use of the thyroid extract 
usually aggravates the symptoms of exophthalmic goitre. The most suc- 
cessful line of treatment has been that directed to diminish the bulk of 
the goitre. These are some of the considerations which favor the view 
that the symptoms are due to disturbed function of the thyroid gland, 
probably to a hypersecretion of certain materials, which induce a sort of 
chronic intoxication. Myxcedema may develop in the late stages, and 
there are transient oedema and in a few cases scleroderma, which indicate 
that the nutrition of the skin is involved. Persistence of the thymus is 
almost the rule (Hector Mackenzie), but its significance is unknown. 

Symptoms. — Acute and chronic forms may be recognized. In the 
acute form the disease may develop with great rapidity. In a patient of 
J. H. Lloyd's, of Philadelphia, a woman, aged thirty-nine, who bad been 
considered perfectly healthy, but whose friends had noticed that for some 
time her eyes looked rather large, was suddenly seized with intense vomit- 
ing and diarrhoea, rapid action of the heart, and great throbbing of the 



838 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



arteries. The eyes were prominent and staring and the thyroid gland was 
found much enlarged and soft. The gastro-intestinal symptoms contin- 
ued, the pulse became more rapid, the vomiting was incessant, and the 
patient died on the third day of the illness. Only the abdominal and 
thoracic organs could be examined and no changes were found. Two 
rapidly fatal cases occurred at the Philadelphia Hospital, one of which, 
under F. P. Henry's care, had marked cerebral symptoms. The acute cases 
are not always associated with delirium. In a case reported by Sutcliff 
death occurred within three months from the onset of the symptoms, owing 
to repeated and uncontrollable vomiting. More frequently the onset is 
gradual and the disease is chronic. There are four characteristic symptoms 
of the disease — exophthalmos, tachycardia, enlargement of the thyroid, 
and tremor. 

Tachycardia. — Eapid heart action is only one of a series of remarkable 
vascular phenomena in the disease. The pulse-rate at first may be not 
more than 95 or 100, but when the disease is established it may be from 
140 to 160, or even higher. Irregularity is not common, except toward 
the close. In a well-developed case the visible area of cardiac pulsation is 
much increased, the action is heaving and forcible, and the shock of the 
heart-sounds is well felt. The large arteries at the root of the neck throb 
forcibly. There is visible pulsation in the peripheral arteries. The capil- 
lary pulse is readily seen, and there are few diseases in which one may see 
at times with greater distinctness the venous pulse in the veins of the hand. 
The throbbing pulsation of the arteries may be felt even in the finger tips. 
On auscultation murmurs are usually heard over the heart, a loud apex 
systolic and loud bruits at the base and over the manubrium. The sounds 
of the heart may be very intense. In rare instances they may be heard 
at some distance from the patient; according to Graves, as far as four 
feet. 

Exophthalmos, which may be unilateral, usually follows the vascular 
disturbance. It is readily recognized by the protrusion of the balls, and 
partly by the fact that the lids do not completely cover the sclerotics, so 
that a rim of white is seen above and below the cornea. The protrusion 
may become very great and the eye may even be dislocated from the socket, 
or both eyes may be destroyed by panophthalmitis, a condition present in 
one of Basedow's cases. The vision is normal. Graefe noted that when 
the eyeball is moved downward the upper lid does not follow it as in health. 
This is known as Graefe's sign. It seems to be rare; it was not present 
in any one of 17 cases examined at my clinic (Oppenheimer). The palpebral 
aperture is wider than in health, owing to spasm or retraction of the upper 
lid (Stellwag's .sign). The patient winks less frequently than in health. 
Moebius has called attention to the lack of convergence of the two eyes. 
Changes in the pupils and in the optic nerves are rare. Pulsation of the 
retinal arteries is common. 

Enlargement of the thyroid commonly develops with the exophthalmos. 
It may be general or in only one lobe, and is rarely so large as in ordinary 
goitre. The vessels are usually much dilated, and the whole gland may 
be seen to pulsate. A thrill may be felt on palpation and on auscultation 



DISEASES OF THE THYROID GLAND. 



839 



a loud systolic murmur, or more commonly a bruit de (liable. A double 
murmur is common and is pathognomonic (Guttmann). 

Tremor is the fourth cardinal symptom, and was really first described 
by Basedow. It is involuntary, fine, about eight to the second. It is of 
great importance in the diagnosis of the early cases. 

Among other symptoms which may develop are anaemia, emaciation, 
and slight fever. Attacks of vomiting and diarrhoea may occur. The 
latter may be very severe and distressing, recurring at intervals. The great- 
est complaint is of the forcible throbbing in the arteries, often accompanied 
with unpleasant flushes of heat and profuse perspirations. Skin symptoms 
are not infrequent — pigmentation, which may be intense and simulate 
Addison's disease, patches of leucoderma, or atrophy of pigment, and 
urticaria. Patches of solid oedema have been seen. Occasionally myx- 
cedema has been present. In the very acute case above referred to urticaria 
was a prominent symptom. Occasionally pruritus is an early and most 
distressing symptom. I have seen one case in which it persisted and became 
almost unbearable. Irritability of temper, change in disposition, and great 
mental depression have been described. An important complication is 
acute mania, in which the patient may die in a few days. Weakness of 
the muscles is not uncommon, particularly a feeling of " giving way " of 
the legs. If the patient holds the head down and is asked to look up with- 
out raising the head, the forehead remains smooth and is not wrinkled, as 
in a normal individual (Joffroy). A feature of interest noted by Charcot 
is the great diminution in the electrical resistance, which may be due to the 
saturation of the skin with moisture owing to the vaso-motor dilatation 
(Hirt). Bryson has noted the fact that the chest expansion may be greatly 
diminished. The emaciation may be extreme. Glycosuria and albuminuria 
are not infrequent complications. True diabetes may also develop. 

The course of the disease is usually chronic, lasting several years. After 
persisting for six months or a year the symptoms may disappear. There 
are remarkable instances in which the symptoms have come on with great 
intensity, following fright, and have disappeared again in a few days. A 
certain proportion of the cases get well, but when the disease is well de- 
veloped recovery is rare. 

Treatment. — Medicinal measures are notoriously uncertain. The 
combination of digitalis and iron may be tried, and, when there is anaemia, 
often does good. I have never seen any advantage from the use of aco- 
nite or veratrum viride. The tincture of strophanthus will sometimes 
reduce the rapidity of the heart's action. Ergot is warmly recommended 
by some writers. Belladonna gives relief occasionally, and should be ad- 
ministered until the dryness of the throat is obtained. I have seen one case 
of apparent cure under its use. No measures are so successful as protracted 
rest in bed with an ice-bag applied continuously, by day, over the heart, or, 
what is sometimes more agreeable, over the lower part of the neck and 
manubrium sterni. I have known the pulse to be reduced in this way 
from 140 to 90. Electricity has been much lauded and instances of cure 
have been reported. In many cases temporary improvement certainly 
follows the use of the galvanic current. Erb states that the anode should 



840 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



be placed over the cervical spine and the cathode upon the peripheral 
nerves. The use of the thyroid extract has not been successful. The thy- 
mus extract has not proved satisfactory. The treatment of the disease by 
small doses of opium has been successful in some cases (XEusser). Opera- 
tive measures seem to offer the greatest relief. Eemoval of one lobe of the 
gland, tying the arteries of the gland, and exothyropexia have all been 
tried. The patients, as a rule, stand the anaesthetic badly; death on the 
table is more frequent than the published records indicate. Eecently good 
results have been reported from the division of the cords of the cervical 
sympathetic. 

4. Myxcede^ia (Atliyrea). 

Definition. — A constitutional affection, due to the loss of function 
of the thyroid gland. The disease, which was described by Sir William 
Gull as a cretinoid change, and later by Ord, is characterized clinically by 
a myxceclematous condition of the subcutaneous tissues and mental failure, 
-and anatomically by atrophy of the thyroid gland. 

Clinical Forms. — Three groups of cases may be recognized — cretinism, 
myx oedema proper, and operative myxcedema. 

Cretinism. 

This remarkable impairment of nutrition follows absence or loss of 
•function of the thyroid gland, either congenital or appearing at any time 
before puberty. There is remarkable retardation of development, reten- 
tion of the infantile state, and an extraordinary disproportion between the 
different parts of the body. Two forms of cretinism are recognized, the 
sporadic and the endemic. In the sporadic form the gland may be con- 
genially absent, it may be atrophied after one of the specific fevers, or the 
•condition may develop with goitre. Since we have learned to recognize the 
disease it is surprising how many cases have been reported. I was able to 
collect 60 cases in this country to May 1, 1897.* 

The condition is rarely recognized before the infant is six or seven 
months old. Then it is noticed that the child does not grow so rapidly 
and is not bright mentally. The tongue looks large and hangs out of the 
month. The hair may be thin and the skin very dry. Usually by the end 
of the first year and during the second }^ear the signs of cretinism become 
very marked. The face is large, looks bloated, the eyelids are puffy and 
swollen; the alas nasi are thick, the nose looks depressed and flat. Denti- 
tion is delayed, and the teeth which appear decay early. The abdomen 
is swollen, the legs are thick and short, and the hands and feet are undevel- 
oped and pudgy. The face is pale and sometimes has a waxy, sallow tint. 
The fontanelles remain open; there is much muscular weakness, and the 
child cannot support itself. In the supraclavicular regions there are large 
pads of fat. The child does not develop mentally: there are various grades 
of idiocy and imbecility. 



* Sporadic cretinism in America, Transactions of the Congress of American Physi- 
cians and Surgeons, vol. iv. 



DISEASES OF THE THYROID GLAND. 



841 



A very interesting form is that in which, after the child has thriven 
and developed until its fourth or fifth year, or even later, the symptoms 
begin after a fever, in consequence of an atrophy of the gland. Parker 
suggests for this variety the name juvenile myxcedema. 

Endemic cretinism develops under local conditions, as yet unknown, in 
association with goitre. It is met with chiefly in Switzerland and parts 
of Italy and France. The common opinion is that it too is associated with 
loss of function of the thyroid. 

The diagnosis of cretinism is very easy after one has seen a case or good 
illustrations. Infants a year or so old sometimes become flabby, lose their 
vivacity, or show a protuberant abdomen and lax skin with slight cretinoid 
appearance. These milder forms, as they have been termed, are probably 
due to transient functional disturbance in the gland. There is rarely any 
difficulty in recognizing the different other types of idiocy. The condi- 
tion known as fcetal rickets, achondroplasia, or the chondrodystrophia fetalis, 
is more likely to be mistaken for cretinism. The children which survive 
birth grow up as a remarkable form of dwarfs, characterized by shortness 
of the limbs (micromelia) and enormous enlargement of the articulations, 
due to hyperplasia of the cartilaginous ends of the bones. Infantilism — 
the condition characterized by a preservation in the adult of the exterior 
form of infancy with the non-appearance of the secondary sexual char- 
acters — could scarcely be mistaken for cretinism. 

Myxcedema of Adults {GulVs Disease), 

In this, women are very much more frequently affected than men — in 
a ratio of 6 to 1. The disease may affect several members of a family, and 
it may be transmitted through the mother. In some instances there has 
been first the appearance of exophthalmic goitre. Though occurring most 
•commonly in women, it seems to have no special relation to the catamenia 
■or to pregnancy; the symptoms of myxcedema may disappear during preg- 
nacy or may develop post partum. Myxcedema and exophthalmic goitre 
may occur in sisters. It is not so common in this country as in England. 
The symptoms of this form, as given by Ord,* are marked increase in 
the general bulk of the body, a firm, inelastic swelling of the skin, which 
does not pit on pressure; dryness and roughness, which tend, with the 
swelling, to obliterate in the face the lines of expression; imperfect nutri- 
tion of the hair; local tumefaction of the skin and subcutaneous tissues, 
particularly in the supraclavicular region. The physiognomy is altered 
in a remarkable way: the features are coarse and broad, the lips thick, the 
nostrils broad and thick, and the month is enlarged. Over the cheeks, 
sometimes the nose, there is a reddish patch. There is a striking slowness 
of thought and of movement. The memory becomes defective, the patient- 
grow irritable and suspicions, and there may be headache. In some in- 
stances there are delusions and hallucinations, leading to a final condition 
of dementia. The gait is heavy and slow. The temperature may be below 



* Report on MyxnHlema. Clinical Society's Transactions, 1888. 
52 



842 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



normal. The functions of the heart, lungs, and abdominal organs are- 
normal. Haemorrhage sometimes occurs. Albuminuria is sometimes pres- 
ent, more rarely glycosuria. Death is usually due to some intercurrent 
disease, most frequently tuberculosis (Greenfield). The thyroid gland is- 
diminished in size and may become completely atrophied and converted 
into a fibrous mass. The subcutaneous fat is abundant, and in one or two, 
instances a great increase in the mucin has been found. 

The course of the disease is slow but progressive, and extends over ten 
or fifteen years. A condition of acute and temporary myxcedema may 
develop in connection with enlargement of the thyroid in young persons.. 
Myxeedema may follow exophthalmic goitre. In other instances the symp- 
toms of the two diseases have been combined. I have reported a case in 
which a young man became bloated and increased in weight enormously 
during three months, then developed tachycardia with tremor and active- 
delirium, and died within six months of the onset of the symptoms. 

Operative Myxcedema ; Cachexia Strumipriva. 

Horsley, in a series of interesting experiments, showed that complete 
removal of the thyroid in monkeys was followed by the production of a 
condition similar to that of myxcedema and often associated with spasms 
or tetanoid contractures, and followed by apathy and coma. When the 
monkeys were kept warm myxcedema was averted, and, instead of an acute 
myxcedema, the animals developed a condition which closely resembled 
cretinism. An identical condition may follow extirpation of the thyroid 
in man. Kocher, of Bern, found that after complete extirpation a cachectic 
condition followed in many cases, the symptoms of which are practically" 
identical with those of myxcedema. The disease follows only a certain 
number of total and a much smaller proportion of partial removals of the 
thyroid gland. Of 408 cases, in 69 the operative myxcedema developed. 
It has been thought that if a small fragment of the thyroid remains, 
or if there are accessory glands, which in animals are very common, 
these symptoms do not develop. It is possible that in men, in the cases 
of complete removal, the accessory fragments subserve the function of 
the gland. Operative myxcedema is very rare in America; I have been 
able to find only 2 cases in this country. McGraw's case, referred to in- 
previous editions of this work, has since been cured with the thyroid 
extract. 

The diagnosis of myxcedema is easy, as a rule. The general aspect of 
the patient — the subcutaneous swelling and the pallor — suggests Bright's 
disease, which may be strengthened by the discovery of tube-casts and of 
albumin in the urine; but the solid character of the swelling, the exceed- 
ing dryness of the skin, the yellowish-white color, the low temperature,, 
the loss of hair, and the dull, listless mental state should suffice to differ- 
entiate the two conditions. In dubious cases not too much stress should 
be laid upon the supraclavicular swellings. There may be marked fibro- 
fatty enlargements in this situation in healthy persons, the supraclavicular 
pseudo-lipomata of Verneuil. 



DISEASES OF THE THYMUS GLAND. 



843 



Treatment. — The patients suffer in cold and improve greatly in warm 
weather. They should therefore be kept at an even temperature, and 
should, if possible, move to a warm climate during the winter months. Re- 
peated warm baths with shampooing are useful. Our art has made no 
more brilliant advance than in the cure of these disorders due to disturbed 
function of the thyroid gland. That we can to-day rescue children other- 
wise doomed to helpless idiocy — that we can restore to life the hopeless 
victims of myxcedema — is a triumph of experimental medicine for which we 
are indebted very largely to Victor Horsley and to his pupil Murray. Trans- 
plantation of the gland was first tried; then Murray used an extract sub- 
cutaneously. Hector Mackenzie in London and Howitz in Copenhagen 
introduced the method of feeding. We now know that the gland, taken 
either fresh, or as the watery or glycerin extract, or dried and powdered, 
is equally efficacious in a majority of all the cases of myxcedema in infants 
or adults. Many preparations are now on the market, but it makes little 
difference how the gland is administered. The dried powdered gland and 
the glycerin extract are most convenient. It is well to begin with the 
powdered gland, 1 grain three times a day, of the Parke-Davis preparation, 
or one of the Burroughs and Welcome tablets. The dose may be increased 
gradually until the patient takes 10 or 15 grains in the day. In many cases 
there are no unpleasant symptoms; in others there are irritation of the 
skin, restlessness, rapid pulse, and delirium; in rare instances tonic spasms, 
the condition to which the term thyroidism is applied. The results, as a 
rule, are most astounding — unparalleled by anything in the whole range 
of curative measures. Within six weeks a poor, feeble-minded, toad-like 
caricature of humanity may be restored to mental and bodily health. Loss 
of weight is one of the first and most striking effects; one of my patients 
lost over 30 pounds within six weeks. The skin becomes moist, the urine 
is increased, the perspiration returns, the temperature rises, the pulse-rate 
quickens and the mental torpor lessens. Ill effects are rare. Two or three 
cases with old heart lesions have died during or after the treatment; in one 
instance a temporary condition of Graves' disease was induced. 

The treatment, as Murray suggests, must be carried out in two stages — 
one, early, in which full doses are given until the cure is effected; the other, 
the permanent use of small doses sufficient to preserve the normal metab- 
olism. In the cases of cretinism it seems to be necessary to keep up the 
treatment indefinitely. I have seen several instances of remarkable relapse 
follow the cessation of the use of the extract. 



XI. DISEASES OF THE THYMUS GLAND. 

The functions of this gland are unknown. It is a suggestive fact that 
Baumann found in it minute quantities of a compound containing iodine. 
It lias been thought that its internal secretion has an inilnence in com- 
bating infective agents. The weight of the organ is about 14 grammes 
at birth, about 20 at the ninth month, and 25 to 30 at the second year. 



844 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 



The organ, after reaching its largest size about the end of the second 
year, gradually wastes, until at the time of puberty it is a mere fatty rem- 
nant, in which, however, there are " traces of its original structure in the 
form of small masses of thymus corpuscles, and even of concentric cor- 
puscles " (Quain). A complete consideration of the affections of this gland 
is to be found in Friedleben's remarkable monograph, Die Physiologie der 
Thymusdruse, 1858. The following are the most important conditions: 

I. Persistence of the organ after the fifteenth year, met with occa- 
sionally, but under circumstances so varied that a satisfactory explanation 
cannot be offered. It is said that the existence of the gland may be deter- 
mined by the presence of an area of dulness along the left sternal border 
from the second to the fourth ribs. 

II. Hypertrophy of the Thymus. — The size of the gland varies Avidely, 
so that it is difficult to define exactly the limits between persistence and 
enlargement. The condition is of interest from three standpoints: (a) The 
supposed occurrence of thymic asthma, due to pressure from the enlarged 
gland. A number of observers have attributed the symptoms of laryngismus 
stridulus to pressure exerted by the enlarged thymus. Many German writers 
consider thymic asthma identical with the laryngismus stridulus of English 
authors, who, as a rule, have laid no stress whatever on the association. 
There can be, I think, no question that the ordinary laryngismus seen in 
rickety children is a convulsive affection and is not the result of compression. 
But a very greatly enlarged thymus may seriously hamper the structures 
within the thorax. Jacobi, in his monograph on the gland (Transactions of 
the Association of American Physicians, vol. iii), states that in an infant of 
eight months the distance between the manubrium sterni and the vertebral 
column is 2.2 cm., a space which he thinks might be completely filled by 
an enlarged and congested thymus. Siegel's case also points to the possi- 
bility of this compression. A boy aged two years and a half had had for 
two weeks cough and bronchial rales with dyspnuea, which was more or 
less constant with nocturnal exacerbations. Laryngismus stridulus was 
diagnosed. Tracheotomy was performed shortly after admission without 
relief, but when subsequently the anterior mediastinum was opened from 
above by extending the incision from the tracheotomy wound, a piece of 
the thymus as large as a hazel-nut appeared with each inspiration. The 
gland was drawn up with forceps and fastened by three stitches to the 
fascia over the sternum. The child rested quietly after the operation, had 
no dyspnoea, and made a complete recovery (Berl. klin. Woch., 1896, No. 
40). From a child aged two months (dyspnoeic from the eighth day) 
Koenig removed a portion of the thymus, leaving the substernal part. 
These are cases that go far to disprove Friedleben's dictum — es giebt Tt'ein 
asthma thymicum. 

(b) Thymus Enlargement and Sudden Death. — In considering the ques- 
tion of the so-called lymphatic constitution, with which an enlarged thy- 
mus is usually associated, we have spoken of the occurrence of sudden death. 
Two groups of cases are met with in the literature: First, such instances 
as those described by Grawitz, Jacobi, and others, in which young infants 
have been either found dead in bed or have been attacked suddenly with 



DISEASES OF THE THYMUS GLAND. 



845 



dyspnoea, have become cyanotic and died in a few minutes. In such cases 
the thymus has been found greatly enlarged, and death has been thought 
to be directly due either to pressure on the air-passages, pressure on the 
pneumogastric (causing spasm of the glottis), or pressure on the great ves- 
sels. To the second group belong the cases in adults which have been de- 
scribed of late by Xordmann, Paltauf, Ohlmacher, and others, in which 
the sudden death has occurred under such conditions as anaesthesia or 
while bathing. In a number of these cases not only has the thymus been 
found enlarged, but the spleen and lymphatic tissues generally. The ques- 
tion is one of considerable medico-legal interest, and has been spoken of 
under Lymphatism. 

Bolleston reports a case of sudden death after signs of cardiac failure 
lasting for only twenty minutes, in which there was hyperplasia of a per- 
sistent thymus. The gland with the trachea weighed 11 ounces. 

(c) Thymus Gland and Exophthalmic Goitre. — That there is some asso- 
ciation between these conditions is urged on two grounds: First, the per- 
sistence of the gland in Graves' disease. W, W. Ord and Hector Mac- 
kenzie state that it has been found enlarged in all the cases recently exam- 
ined at St. Thomas's Hospital. Hektoen concludes from a very thorough 
study of the question that the coexistence is more than accidental. Sec- 
ondly, the good results which are stated to follow the feeding of the thymus 
gland in Graves' disease are held to bear out the idea that the enlargement 
during life is compensatory. The general conclusion, however, reached by 
Hector Mackenzie and by Kinnicutt is that the thymus feeding has at best 
only slight influence upon Graves' disease. 

It is interesting to note in connection with the question of enlarged 
thymus and sudden death that two of Hale White's cases of exophthalmic 
goitre died suddenly, and autopsy showed no reasonable cause of death. 

Among other conditions with which enlarged thymus has been associ- 
ated may be mentioned epilepsy (Ohlmacher). 

III. Other Morbid Conditions of the Thymus. — Hemorrhages are not 
uncommon, and are found particularly in children who have died of 
asphyxia. 

Tumors of the gland, particularly sarcoma and lympho-sarcoma, have 
been frequently described. Many mediastinal tumors originate in the rem- 
nants of the thymus. Dermoid tumors and cysts have also been met with. 
Tuberculosis of the gland, chiefly in the form of miliary nodules, is well 
described in Jacobi's monograph. There is a well-authenticated case in 
which it was primary. Focal necroses in diphtheria have also been de- 
scribed by Jacobi. 

Abscess of the Thymus. — Dubois, in 1850, noted the occurrence of foci 
of suppuration in the gland in subjects of congenital syphilis. Throughout 
it round or fissure-like cavities are seen filled with a purulent fluid. Chiari 
states that some of these supposed abscesses are areas of post-mortem soften- 
ing, or cysts lined with flattened epithelium containing detritus of thymus 
cells. In one case Jacobi found a small gumma. 



SECTION IX. 



DISEASES OF THE KIDNEYS. 



I. MALFORMATIONS. 

Newman classifies the malformations of the kidney as follows: A. Dis- 
placements without mobility — (1) congenital displacement without de- 
formity; (2) congenital displacement with deformity; (3) acquired dis- 
placements. B. Malformations of the kidney. I. Variations in number — 
(a) supernumerary kidney; (b) single kidney, congenital absence of one 
kidney, atrophy of one kidney; (c) absence of both kidneys. II. Varia- 
tions in form and size — (a) general variations in form, lobulation, etc.; (b) 
hypertrophy of one kidney; (c) fusion of two kidneys — horseshoe kidney, 
sigmoid kidney, disk-shaped kidney. C. Variations in pelvis, ureters, and 
blood-vessels. 

The fused kidneys may form a large mass, which is often displaced, being 
either in an iliac fossa or in the middle line of the abdomen, or even in the 
pelvis. Under these circumstances it may be mistaken for a new growth. 
In Polk's case the organ was removed under the belief that it was a floating 
kidney.* The patient lived eleven days, had complete anuria, and it was 
found post mortem that a single unsymmetrical kidney, as this form is 
called, had been removed. 

II. MOVABLE KIDNEY. 

(Floating Kidney ; Palpable Kidney ; Renmobilis; Nephroptosis). 

The kidney is held in position by its fatty capsule, by the peritonaeum 
which passes in front of it, and by the blood-vessels. Normally the kidney 
is firmly fixed, but under certain circumstances one or the other organ, 
more rarely both, becomes movable. In very rare cases the kidney is sur- 
rounded, to a greater or less extent, by the peritonaeum, and is anchored 
at the hilus by a mesonephron. Some would limit the term floating kidney 
to this condition. 

Movable kidney is almost always acquired. It is more common in 



846 



* New York Medical Journal, 1883. 



MOVABLE KIDNEY. 



847 



•women. Of the 667 cases collected in the literature by Kuttner, 584 were 
in women and only 83 in men. It is more common on the right than on 
the left side. Of 727 cases analyzed by this author, it occurred on the right 
in 553 cases, on the left in 81, and on both sides in 93. The greater fre- 
quency of the condition in women may be attributed to compression of the 
lower thoracic zone by tightlacing, and, more important still, to the relaxa- 
tion of the abdominal walls which follows repeated pregnancies. This does 
jiot account for all the cases, as movable kidney is by no means uncommon 
in nullipara?. Drummond believes that in a majority of the cases there is 
-a congenitally relaxed condition of the peritoneal attachments. The condi- 
tion has been met with in infants. Wasting of the fat about the kidney 
may be a cause in some instances. Trauma and the lifting of heavy weights 
are occasionally factors in its production. The kidney is sometimes dragged 
down by tumors. The greater frequency on the right side is probably asso- 
ciated with the position of the kidney just beneath the liver, and the de- 
pression to which the organ is subjected with each descent of the diaphragm 
in inspiration. 

And, lastly, movable kidney is met with in many cases which present 
that combination of neurasthenia with gastro-intestinal disturbance which 
has been described by G-lenard as enteroptosis (see p. 541). 

To determine the presence of a movable kidney the patient should be 
placed in the dorsal position, with the head moderately low and the ab- 
dominal walls relaxed. The left hand is placed in the lumbar region behind 
the eleventh and twelfth ribs; the right hand in the hypochondriac region, 
in the nipple line, just under the edge of the liver. Bimanual palpation 
may detect the presence of a firm, rounded body just below the edge of the 
ribs. If nothing can be felt, the patient should be asked to draw a deep 
breath, when, if the organ is palpable, it is touched by the fingers of the 
right hand. Various grades of mobility may be recognized. It may be 
possible barely to feel the lower edge on deep palpation — palpable kidney — 
or the organ may be so far displaced that on drawing the deepest breath 
the fingers of the right hand may be, in a thin person, slipped above the 
upper end of the organ, which can be readily held down, but cannot be 
pushed below the level of the navel — movable kidney. In a third group of 
•cases the organ is freely movable, and may even be felt just above Poupart's 
ligament, or may be in the middle line of the abdomen, or can even be 
pushed over beyond this point. To this the term floating kidney is appro- 
priate. 

The movable kidney is not painful on pressure, except when it is grasped 
very firmly, when there is a dull pain, or sometimes a sickening sensation. 
Examination of the patient from behind may show a distinct flattening 
in the lumbar region on the side in which the kidney is mobile. 

Symptoms. — In a large majority of cases there are no symptoms, and 
if detected accidentally it is well not to let the patient know of its presence. 
Far too much stress has been laid upon the condition of late years. In 
other instances there is pain in the lumbar region or a sense of dragging 
and discomfort, or there may be intercostal neuralgia. In a large group 
the symptoms are those of neurasthenia with dyspeptic disturbance. In 



84S 



DISEASES OF THE KIDNEYS. 



women the hysterical symptoms may be marked, and in men various grades 
of hypochondriasis. The gastric disturbance is usually a form of nervous 
dyspepsia. Dilatation of the stomach has been observed, owing, as suggested 
by Bartels, to pressure of the dislocated kidney upon the duodenum. This 
view has been supported by Oser, Landau, and Ewald. On the other hand, 
Litten holds that the dilatation of the stomach is the cause of the mobility 
of the kidney, and he found in 40 cases of depression and dilatation of the 
stomach 22 instances of dislocation of the kidney on the right side. My 
own experience coincides with that of Drummond, who has very excep- 
tionally found the two conditions to coexist. The association, however,, 
with a depressed stomach is certainly not uncommon in women. Constipa- 
tion is not infrequent. Some writers have described pressure upon the 
gall-ducts, with jaundice, but it is not very likely to occur. Faecal accumu- 
lation and even obstruction may be associated with the displaced organ. 

DietVs Crises. — In floating kidney there are attacks characterized by 
severe abdominal pain, chills, nausea, vomiting, fever, and collapse. Scarcely 
any mention is made of such symptoms, which were first described by Dietl 
in 1864, and a more widespread knowledge of their occurrence in connec- 
tion with this condition is desirable. My attention was called to them in 
1880 by Palmer Howard in the case of a stout lady, who suffered repeatedly 
with the most severe attacks of abdominal pain and vomiting, which con- 
stantly required morphia. A tumor was discovered a little to the right of 
the navel, and the diagnosis of probable neoplasm was concurred in by 
Flint (Sr.) and Gaillard Thomas. The patient lost weight rapidly, became 
emaciated, and in the spring of 1881 again went to Xew York, where she 
saw A"an Buren, who diagnosed a floating kidney and said that these parox- 
ysms were associated with it in a gouty person. He cut off all stimulants, 
reassured the lady that she had no cancer, and from that time she rapidly 
recovered, and the attacks have been few and far between. In this patient 
any overindulgence in eating or in drinking is still liable to be followed 
by a very severe attack. These attacks may also be mistaken for renal colic,, 
and the operation of nephrotomy has been performed. 

In other instances the attacks of pain may be thought to be due to in- 
testinal disease or to recurring appendicitis. The cause of these parox- 
ysmal attacks is not quite clear. Dietl thought they were due to strangu- 
lation of the kidney or to twists or kinks in the renal vessels due to the 
extreme mobility. During the attacks the urine is sometimes high-colored 
and contains an excess of uric acid or of the oxalates. It is stated, too, 
that blood or pus may be present. The kidney may be tender, swollen,, 
and less freely movable. Cheyne describes intermittent hematuria in this 
condition. 

Intermittent lajdro nephrosis is sometimes associated with movable kid- 
in -v. Three cases are reported in my Lectures on Abdominal Tumors. In 
two the condition has been completely relieved by a well-adapted pad and 
bell ; in the third, attacks recur at long intervals. 

The diagnosis is rarely doubtful, as the shape of the organ is usually 
distinctive and the mobility marked. Tumors of the gall-bladder, ovarian 
and tumors of the bowels may in rare instances be confounded 

with it. 



CIRCULATORY DISTURBANCES. 



849 



Treatment. — The kidney has been extirpated in many instances, but 
the operation is not without risk, and there have been several fatal cases. 
Stitching of the kidney — nephrorrhaphy — as recommended by Harm, is the 
most suitable procedure, and statistics published by Keen show that relief 
is afforded in many cases by the procedure, though not in all. Treatment 
designed to increase fat-formation often helps to hold the kidney in place. 

In many instances the greatest relief is experienced from a bandage and 
pad. It should be applied in the morning, with the patient in the dorsal or 
knee-breast position, and she should be taught how to push up the kidney. 
An air pad may be used if the organ is sensitive. In other cases a broad 
bandage well padded in the lower abdominal zone pushes up the intestines 
and makes them act as a support. In the attacks of severe colic morphia 
is required. When dependent, as seems sometimes the case, upon an excess 
of uric acid or the oxalates, the diet must be carefully regulated. 

For an exhaustive consideration of all aspects of the subject, see Fischer, 
in Nos. 1-5 of the Centralblatt f. d. Grenzgebiete der Medicin und Chirur- 
gie, 1898. 

III. CIRCULATORY DISTURBANCES. 

Normally the secretion of urine is accomplished by the maintenance 
of a certain blood-pressure within the glomeruli and by the activity of 
the renal epithelium. Bowman's views on this question have been gen- 
erally accepted, and the watery elements are held to be filtered from the 
glomeruli; the amount depending on the rapidity and the pressure of the 
blood current; the quality, whether normal or abnormal, depending upon 
the condition of the capillary and glomerular epithelium; while the greater 
portion of the solid ingredients are excreted by the epithelium of the con- 
voluted tubules. The integrity of the epithelium covering the capillary 
tufts within Bowman's capsule is essential to the production of a normal 
urine. If under' any circumstances their nutrition fails, as when, for ex- 
ample, the rapidity of the blood current is lowered, so that they are deprived 
of the necessary amount of oxygen, the material which filters through is 
no longer normal (i. e., water), but contains serum albumin. Cohnheim 
has shown that the renal epithelium is extremely sensitive to circulatory 
changes, and that compression of the renal artery for only a few minutes 
causes serious disturbance. 

The circulation of the kidney is remarkably influenced by reflex stimuli 
coming from the skin. Exposure to cold causes heightened blood-pressure 
within the kidneys and increased secretion of urine. Bradford lias shown 
that after excision of portions of the kidney, to as much as one third of 
the total weight, there is a remarkable increase in the flow of urine 

Congestion of the Kidneys. — (1) Active Congestion ; Hyperemia. — 
Acute congestion of the kidney is met with in the early stage of nephritis, 
whether due to cold or to the action of poisons and severe irritants. Tur- 
pentine, cubebs, cantharides, and copaiba are nil stated to cause extreme 
hyperemia of the organ. The most typical congestion of the kidney which 
we see post mortem is that in the early stage of acute Bright's disease, when 



■850 



DISEASES OF THE KIDNEYS. 



the organ may be large, soft, of a dark color, and on section blood drips 
irom it freely. 

It has been held that in all the acute fevers the kidneys are congested, 
.and that this explained the scanty, high-colored, and often albuminous 
urine. On the other hand, by Koy's oncometer, Walter Mendelson has 
.shown that the kidney in acute fever is in a state of extreme anaemia, small, 
pale, and bloodless; and that this anaemia, increasing with the pyrexia and 
interfering with the nutrition of the glomerular epithelium, accounts for 
the scanty, dark-colored urine of fever and for the presence of albumin. 
In the prolonged fevers, however, it is probable that relaxation of the 
arteries again takes place. Certainly it is rare to find post mortem such 
a condition of the kidney as is described by Mendelson. On the contrary, 
the kidney of fever is commonly swollen, the blood-vessels are congested, 
.and the cortex frequently shows traces of cloudy swelling. However, the 
.circulatory disturbances in acute fevers are probably less important than 
the irritative effects of either the specific agents of the disease or the prod- 
ucts produced in their growth or in the altered metabolism of the tissues. 
The urine is diminished in amount, and may contain albumin and tube- 
casts. 

(2) Passive Congestion; Mechanical Hyperemia. — This is found in cases 
of chronic disease of the heart or lung, with impeded circulation, and as a 
Tesult of pressure upon the renal veins by tumors, the pregnant uterus, or 
.ascitic fluid. In the cardiac kidney, as it is called, the cyanotic induration 
.associated with chronic heart-disease, the organs are enlarged and firm, 
the capsule strips off, as a rule, readily, the cortex is of a deep red color, 
.and the pyramids of a purple red. The section is coarse-looking, the sub- 
stance is very firm, and resists cutting and tearing. The interstitial tissue 
is increased, and there is a small-celled infiltration between the tubules. 
Here and there the Malpighian tufts have become sclerosed. The blood- 
vessels are usually thickened, and there may be more or less granular, fatty, 
or hyaline changes in the epithelium of the tubules. The condition is in- 
deed a diffuse nephritis. The urine is usually reduced, is of high specific 
gravity, and contains more or less albumin. Hyaline tube-casts and blood- 
corpuscles are not uncommon. In uncomplicated cases of the cyanotic in- 
duration uraemia is rare. On the other hand, in the cardiac cases with ex- 
tensive arterio-sclerosis, the kidneys are more involved and the renal func- 
tion is likely to< be disturbed. 



IV. ANOMALIES OF THE URINARY SECRETION. 

1. Anueia. 

Total suppression of urine occurs under the following conditions: 

(1) As an event in the intense congestion of acute nephritis. For a 
time no urine may be formed; more often the amount is greatly reduced. 

(2) More commonly complete anuria is seen in subjects of renal stone, 
"fragments of which block both ureters. Sir William Eoberts calls the con- 



ANOMALIES OF THE URINARY- §ECRETION. 



851 



dition " latent uraemia." There may be very little discomfort, and the 
symptoms are very unlike those of ordinary uraemia. Convulsions occurred 
in only 5 of 41 cases (Herter); headache in only 6; vomiting in only 12. 
Consciousness is retained; the pupils are usually contracted; the tempera- 
ture may be low; there are twitchings and perhaps occasional vomiting. 
Of 41 cases in the literature, 35 occurred in males. Of 36 cases in which 
there was absolute anuria, in 11 the condition lasted more than four days, 
in 18 cases from seven to fourteen days, and in 7 cases longer than four- 
teen days (Herter). 

(3) Cases occur occasionally in which the suppression is prerenal. The 
following are among the more important conditions with which this form 
of anuria may be associated (Hensley): Fevers and inflammations; acute 
poisoning by phosphorus, lead, and turpentine; in the collapse after severe 
injuries or after operations, or, indeed, after the passing of a catheter; in 
the collapse stage of cholera and yellow fever; and, lastly, there is an 
hysterical anuria, of which Charcot reports a case in which the suppression 
lasted for eleven days. Bailey reports the case of a young girl, aged eleven, 
inmate of an orphan asylum, who passed no urine from October 10th to 
December 12th (when 8 ounces were withdrawn), and again from this date to 
March 1st! The question of hysterical deception was considered in the case. 

A patient may live for from ten days to two weeks with complete sup- 
pression. In Polk's case, in which the only kidney was removed, the pa- 
tient lived eleven days. It is remarkable that in many instances there are 
no toxic features. Adams reports a case of recovery after nineteen days of 
suppression. 

In the obstructive cases surgical interference should be resorted to. 
In the non-obstructive cases, particularly when due to extreme congestion 
of the kidney, cupping over the loins, hot applications, free purging, and 
sweating with pilocarpine and hot air are indicated. When the secretion is 
once started diuretin often acts well. Large hot irrigations, with normal' 
salt solution, with Kemp's double-current rectal tubes, should be tried, as 
they are stated to stimulate the activity of the kidneys in a remarkable way. 

2. HEMATURIA. 

The following division may be made of the causes of ha?maturia: 

(1) General Diseases. — The malignant forms of the acute specific fevers. 
Occasionally in leukaemia haematuria occurs. 

(2) Renal Causes. — Acute congestion and inflammation, as in Bright's 
disease, or the effect of toxic agents, such as turpentine, carbolic acid, and 
cantharides. When the carbolic spray was in use many surgeons suffered 
from haematuria in consequence of this poison. Renal infarction, as in 
ulcerative endocarditis. New growths, in which the bleeding is usually 
profuse. In tuberculosis at the onset, when the papillae are involved, there 
may be bleeding. Stone in the kidney is a frequent cause. Parasites: The 
Filaria sanguinis hominis and the Bilharzia cause a form of hematuria met 
with in the tropics. The echinococcus is rarely associated with haemor- 
Thage. It is sometimes met with in floating kidney. 



852 



DISEASES OF THE KIDNEYS. 



(3) Affections of the Urinary Passages. — Stone in the ureter, tumor or 
ulceration of the bladder, the presence of a calculus, parasites, and, very 
rarely, ruptured veins in the bladder. Bleeding from the urethra occa- 
sionally occurs in gonorrhoea and as a result of the lodgment of a calculus. 
Hematuria may be an early symptom in enlarged prostate. 

(4) Traumatism. — Injuries may produce bleeding from any part of the 
urinary passages. By a fall or blow on the back the kidney may be rup- 
tured, and this may be followed by very free bleeding; less commonly the 
blood comes from injury of the bladder or of the prostate. Blood from the 
urethra is frequently due to injury by the passage of a catheter, or some- 
times to falls. Transient hematuria follows all operations on the kidney. 

And, lastly, there is a very interesting group, carefully studied of late 
years, particularly by Klemperer and M. L. Harris, in which no known 
lesions have been found. It is probably in this group of cases that Gull's 
" renal epistaxis "occurs. Harris has recently collected 18 of these cases 
from the literature. The first-named author thinks it is a form of angio- 
neurotic hematuria. An interesting point is that in the 18 cases collected 
by Harris nephrotomy was done; of these, 9 cases were completely re- 
lieved. 

Of special interest is the malarial hematuria which prevails in certain 
districts and has already been considered in the section on paludism. 

The diagnosis of hematuria is usually easy. The color of the urine 
varies from a light smoky to a bright red, or it may have a dark porter 
color. Examined with the microscope, the blood-corpuscles are readily 
recognized, either plainly visible and retaining their color, in which case 
they are usually crenated, or simply as shadows. In ammoniacal urine 
or urines of low specific gravity the haemoglobin is rapidly dissolved from 
the corpuscles, but in normal urine they remain for many hours unchanged. 

For other tests the student is referred to the works on Clinical Diag- 
nosis, by Simon and by von Jaksch. 

It is important to distinguish between blood coming from the bladder 
and from the kidneys, though this is not always easy. From the bladder 
the blood may be found only with the last portions of urine, or only at the 
termination of micturition. In haemorrhage from the kidneys the blood 
and urine are intimately mixed. Clots are more commonly found in the 
blood from the kidneys, and may form moulds of the pelvis or of the ureter. 
When the seat of the bleeding is in the bladder, on washing out this organ,, 
the water is more or less blood-tinged; but if the source of the bleeding is 
higher, the water comes away clear. In many instances it is difficult to 
settle the question by the examination of the urine alone, and the symp- 
toms and the physical signs must also be taken into account. Cystoscopic 
examination of the bladder, paying especial attention to the urine flowing 
from each ureteral orifice, and catheterization of the ureters are aids in 
the diagnosis of doubtful cases. 

3. H^MOGLOBIXURIA. 

This condition is characterized by the presence of blood-pigment in 
the urine. The blood-cells are either absent or in insignificant numbers. 



ANOMALIES OF THE URINARY SECRETION. 



853 



The coloring matter is not hematin, as indicated by the old name, hcerna- 
tinuria, nor in reality always haemoglobin, but it is most frequently methe- 
moglobin. The urine has a red or brownish-red, sometimes quite black 
color, and usually deposits a very heavy brownish sediment. When the 
haemoglobin occurs only in small quantities, it may give a lake or smoky 
color to the urine. Microscopical examination shows the presence of granu- 
lar pigment, sometimes fragments of blood-disks, epithelium, and very often 
darkly pigmented urates. The urine is also albuminous. The number of 
red blood-corpuscles bears no proportion whatever to the intensity of the 
color of the urine. Examined spectroscopically, there are either the two 
•absorption bands of oxyhemoglobin, which is rare, or, more commonly, 
there are the three absorption bands of methaemoglobin, of which the one 
in the red near C is characteristic. Two clinical groups may be distin- 
guished. 

(1) Toxic Hemoglobinuria. — This is caused by poisons which produce 
Tapid dissolution of the blood-corpuscles, such as potassium chlorate in large 
doses, pyrogallic acid, carbolic acid, arseniuretted hydrogen, carbon mon- 
oxide, naphthol, and muscarine; also the poisons of scarlet fever, yellow 
fever, typhoid fever, malaria, and syphilis. According to Bastianelli, hemo- 
globinuria due to the administration of quinine never occurs excepting in 
patients who are suffering or who have recently suffered from malarial 
fever. It has also followed severe burns. Exposure to excessive cold and 
violent muscular exertion are stated to produce hemoglobinuria. A most 
remarkable toxic form occurs in horses, coming on with great suddenness 
and associated with paresis of the hind legs. Death may occur in a few 
hours or a few days. The animals are attacked only after being stalled 
for some days and then taken out and driven, particularly in cold weather. 
The form of hemoglobinuria from cold and exertion is extremely rare. Xo 
instance of it, even in association with frost-bites, came under my observa- 
tion in Canada. Blood transfused from one mammal into another causes 
dissolution of the corpuscles with the production of hemoglobinuria; and, 
lastly, there is the epidemic "hemoglobinuria of the new-born, associated with 
jaundice, cyanosis, and nervous symptoms. 

(2) Paroxysmal Haemoglobinuria. — This rare disease is characterized 
by the occasional passage of bloody urine, in which the coloring matter 
only is present. It is more frequent in males than in females, and occurs 
chiefly in adults. It seems specially associated with cold and exertion, and 
has often been brought on, in a susceptible person, by the use of a cold 
foot-bath. Paroxysmal hemoglobinuria has been found, too, in persons 
subject to the various forms of Raynaud's disease. Many regard the rela- 
tion between these two affections as extremely close; some hold that they 
are manifestations of one and the same disorder. Druitt, the author of the 
well-known Surgical Vade-mecum, has given a graphic description of his 
sufferings, which lasted for many years, and were accompanied with local 
asphyxia and local syncope. The connection, however, is not very common. 
In only one of the cases of Raynaud's disease which I have seen was parox- 
ysmal hemoglobinuria present, and in it epileptic attacks occurred at the 
same time. The relation of the disease to malaria is not so close as has been 



854 



DISEASES OF THE KIDNEYS. 



thought by many writers. Bastianelli asserts that it is practically proved 
that malarial haemoglobinuria occurs only in infections with the aestivo- 
autumnal parasite. It rarely, if ever, occurs in the first attack, usually 
appearing with the first relapse or after repeated relapses. No doubt it has 
been frequently confounded with a malarial haematuria. 

The attacks may come on suddenly after exposure to cold or as a result 
of mental or bodily exhaustion. They may be preceded by chills and 
pyrexia. In other instances the temperature is subnormal. There may be 
vomiting and diarrhoea. Pain in the lumbar region is not uncommon. The 
hemoglobinuria rarely persists for more than a day or two — sometimes, 
indeed, not for a day. There are instances in which, even in the course of 
a single day, there have been two or three paroxysms, and in the intervals 
clear urine has been passed. Jaundice has been present in a number of 
cases. According to Ealfe, paroxysmal haemoglobinuria may alternate with 
general symptoms of the same character, but associated only with the pas- 
sage of albumin and an increased quantity of urea in the urine. In such 
cases he supposes that the toxic agent, whatever its nature, has destroyed 
only a limited number of the corpuscles, the coloring matter of which is 
readily dealt with by the spleen and liver, while the globulin is excreted 
in the urine. The cases are rarely if ever fatal. 

The essential pathology of the disease is unknown, and it is difficult 
to form a theory which will meet all the facts — particularly the relation 
with Raynaud's disease, which is rightly regarded as a vaso-motor disorder. 
Increased haemolysis and solution of the haemoglobin in the blood-serum 
(hsemoglobinaemia) precedes, in each instance, the appearance of the color- 
ing matter in the urine. A full discussion of the subject is to be found 
in F. Chvostek's monograph. Blanc regards it as distinctly nervous in 
origin. 

Treatment. — In all forms of haematuria rest is essential. In that 
produced by renal calculi the recumbent posture may suffice to check the 
bleeding. Full doses of acetate of lead and opium should be tried, then 
ergot, gallic and tannic acid, and the dilute sulphuric acid. The oil of 
turpentine, which is sometimes recommended, is a risky remedy in haema- 
turia. Extr. hamamelis virgin, and extr. hydrastis canad. are also recom- 
mended. Cold may be applied to the loins or dry cups in the lumbar re- 
gion. Incision of the kidney has cured the so-called renal epistaxis. 

The treatment of haemoglobinuria is unsatisfactory. Amyl nitrite will 
sometimes cut short or prevent an attack (Chvostek). During the parox- 
ysm the patient should be kept warm and given hot drinks. Quinine is 
recommended in large doses, on the supposition — as yet unwarranted — 
that the disease is specially connected with malaria. If there is a syphi- 
litic history, iodide of potassium in full doses may be tried. In a warm 
climate the attacks are much less frequent. 

4. Albuminuria. 

The presence of albumin in the urine, formerly regarded as indicative 
of Bright's disease, is now recognized as occurring under many circum- 
stances without the existence of serious organic change in the kidney. Two 



ANOMALIES OF THE URINARY SECRETION. 



855 



groups of cases may be recognized — those in which the kidneys show no- 
coarse lesions, and those in which there are evident anatomical changes. 

Albuminuria without Coarse Renal Lesions, — (a) Functional, so-called 
Physiological Albuminuria. — In a normal condition of the kidney only the 
water and the salts are allowed to pass from the blood. When albuminous 
substances transude there is probably disturbance in the nutrition of the 
epithelium of the capillaries of the tuft, or of the cells surrounding the 
glomerulus. This statement is still, however, in dispute, and Senator, 
Grainger Stewart, and others hold that there is a physiological albuminuria 
which may follow muscular work, the ingestion of food rich in albumin, 
violent emotions, cold bathing, and dyspepsia. The differences of opinion 
on this point are striking, and observers of equal thoroughness and relia- 
bility have arrived at directly opposite conclusions. The presence of albu- 
min in the urine, in any form and under any circumstance, may be regarded 
as indicative of change in the renal or glomerular epithelium, a change, 
however, which may be transient, slight, and unimportant, depending upon 
variations in the circulation or upon the irritating effects of substances- 
taken with the food or temporarily present, as in febrile states. 

Albuminuria of adolescence and cyclic albuminuria, in which the albu- 
min is present only at certain times during the day, are interesting forms. 
A majority of the cases occur in young persons — boys more commonly than 
girk — and the condition is often discovered accidentally. The urine, as a 
rule, contains only a very small amount of albumin, but in some instances 
large quantities are present. The most striking feature is the variability. 
It may be absent in the morning and only present after exertion, or it may 
be greatly increased after taking food, particularly proteids. The quan- 
tity of urine may be but little, if at all, increased, the specific gravity is 
usually normal, and the color may be high. Occasionally hyaline casts 
may be found, and in some instances there has been transient glycosuria. 
As a rule, the pulse is not of high tension and the second aortic sound is 
not accentuated. 

Various forms of this affection have been recognized by writers, such 
as neurotic, dietetic, cyclic, intermittent, and paroxysmal — names which 
indicate the characters of the different varieties. A large proportion of 
the cases get well after the condition has persisted for a variable period. 
This in itself is an evidence that the changes, whatever their nature, are 
transient and slight. In these instances the albumin exists in small quan- 
tity, tube-casts are rarely present, and the arterial tension is not increased. 
In a second group the albumin is more persistent, the amount is larger, 
though it may vary from day to day, and the pulse tension is increased. 
In such instances the persistent albuminuria probably indicates actual 
organic change in the kidney. 

(1>) Febrile Albuminuria. — Pyrexia, by whatever cause produced, may 
cause slight albuminuria. The presence of the albumin is due to slight 
changes in the glomeruli induced by the fever, such as cloudy swelling, 
which cannot be regarded as an organic lesion. It is extremely common, 
occurring in pneumonia, diphtheria, typhoid fever, malaria, and even in 
the fever of acute tonsillitis. The amount of albumin is slight, and it 



$56 



DISEASES OF THE KIDNEYS. 



usually disappears from the urine with the cessation of the fever. Hyaline 
.and even epithelial casts accompany the condition. 

(c) Hcemic Changes. — Purpura, scurvy, chronic poisoning by lead or 
mercury, syphilis, leukaemia, and profound anaemia may be associated 
with slight albuminuria. Abnormal ingredients in the blood, such as 
bile-pigment and sugar, may cause the passage of small amounts of al- 
bumin. 

The transient albuminuria of pregnancy may belong to this hsemic 
group, although in a majority of such cases there are changes in the renal 
tissue. Albumin may be found sometimes after the inhalation of ether or 
chloroform. 

(d) Albuminuria occurs in certain affections of the nervous system. This 
so-called neurotic albuminuria is seen after an epileptic seizure and in apo- 
plexy, tetanus, exophthalmic goitre, and injuries of the head. 

Albuminuria with Definite Lesions of the Urinary Organs. — (a) Con- 
gestion of the kidney, either active, such as follows exposure to cold and 
is associated with the early stages of nephritis, or passive, due to obstructed 
outflow in disease of the heart or lungs, or to pressure on the renal veins 
by the pregnant uterus or tumors. 

(b) Organic disease of the kidneys — acute and chronic Bright's disease, 
amyloid and fatty degeneration, suppurative nephritis, and tumors. 

(c) Affections of the pelvis, ureters, and bladder, when associated with 
the formation of pus. 

Tests for Albumin. — Both morning and evening urine should be 
examined, and in doubtful cases at least three specimens. If turbid, the 
xirine should be filtered, though turbidity from the urates is of no moment, 
since it disappears at once on the application of heat. 

Heat and Nitric-acid Test. — The urine is boiled in a test-tube over a 
spirit-lamp, and a drop of nitric acid is then added. If a cloudiness occurs 
on boiling, it may be due to phosphates, which are dissolved on the addition 
of an acid. Persistence of the cloudiness indicates albumin. 

Heller '$ Test. — A small quantity of fuming nitric acid is poured into 
the test-tube, and with a pipette the urine is allowed to flow gently down 
the side upon the acid. At the line of junction of the two fluids, if albumin 
is present, a white ring is formed. This contact method is trustworthy, 
and, for the routine clinical work, is probably the most satisfactory. A 
diffused haze, due to mucin (nucleo-albumin), is sometimes seen just above 
the white ring of albumin; and in very concentrated urines, or after the 
taking of balsamic remedies, a slight cloudiness may be due to urates or 
uric acid, which clears on heating or warming. A colored ring at the junc- 
tion of the acid and the urine is due to the oxidation of the coloring matters 
in the urine. 

Ferroci/anide-of -potassium and Acetic-acid Test. — Fill an ordinary test- 
tube half full of urine, and add 5 or 6 cc. of potassium-ferrocvanide solu- 
tion (1 in 20). Thoroughly mix the urine and reagent and add 10 to 15 
drops of acetic acid. If albumin be present, a cloudiness varying in de- 
gree according to the amount of albumin will be produced. This is a very 
reliable test, as it precipitates all forms of albumin, acid and alkaline, but 



ANOMALIES OF THE URINARY SECRETION. 



857 



does not precipitate mucin, peptones, phosphates, urates, vegetable alkaloids, 
or the pine acids. 

Sir William Roberts strongly recommends the magnesium-nitric test. 
One volume of strong nitric acid is mixed with five volumes of the satu- 
rated solution of sulphate of magnesium. This is used in the same way as 
the nitric acid in Heller's test. 

Picric acid, introduced by George Johnson, is a delicate and useful 
test for albumin. A saturated solution is used and employed as in the 
contact method. It has been urged against this test that it throws down 
the mucin, peptones, and certain vegetable alkaloids, but these are dis- 
solved by heat. 

For minute traces of albumin the trichloracetic acid may be used, or 
Millard's fluid, which is extremely delicate and consists of glacial carbolic 
acid (95 per cent), 2 drachms; pure acetic acid, 7 drachms; liquor potassse, 
2 ounces 6 drachms. 

A quantitative estimate of the albumin can be made by means of Es- 
bach's tube, but the rough method of heating and boiling a certain quan- 
tity of acidulated urine in a test-tube and allowing it to stand, is often 
employed. The depth of deposit can then be compared with the whole 
amount of urine, and the proportion is expressed as a mere trace, almost 
solid — one fourth, one half, and so on. This, of course, does not give an 
accurate indication of the proportion of albumin in the total quantity of 
urine. For the more elaborate methods the reader is referred to the works 
on urinalysis. 

The above tests refer entirely to serum albumin. Other albuminous 
substances occur, such as albumose, serum globulin, peptones, and hemi- 
albumose or propepton. They are not of much clinical importance. 

Albumosuria. — Traces of albumoses are found in the urine in many 
febrile diseases and in chronic suppuration, and have little clinical signifi- 
cance. Marked and persistent albumosuria is associated with multiple 
myelomata. The first observation in this class was recorded by Bence 
Jones in 1848, as a case of mollifies ossium, with a modified form of albu- 
min in the urine. As Kahler subsequently recognized the condition in a 
similar case as one of multiple myeloma, the Italians have given the disease 
his name. In this country Fitz referred briefly to an instance at a recent 
meeting (1898) of the Association of American Physicians, and lately 
Hamburger (Johns Hopkins Hospital Bulletin, February, 1901) has pub- 
lished from my clinic the details of two cases, with a review of the subject. 
In Bradshaw's case the patient passed at intervals for a year a turbid, milky 
urine, which deposited a copious white sediment. On adding nitric acid to a 
urine containing albumose a white precipitate is formed, which is dissolved 
when the specimen is boiled, but reappears on cooling. 

Globulin rarely occurs in the urine alone, but generally in association 
with serum-albumin. The latter is usually present in greater quantity, but 
in severe organic renal disease and in diabetes Maguire has found that the 
proportion of globulin to albumin is often 2.5 to 1. Senator states that 
more globulin is present with the lardaceous kidney than in other forms of 
nephritis. The clinical significance of globulin is the same as that of 
serum-albumin. 

53 



858 



DISEASES OF THE KIDNEYS. 



Prognosis. — This depends, of course, entirely upon the cause. Fe- 
brile albuminuria is transient, and in a majority of the cases depending 
upon hagmic causes the condition disappears and leaves the kidneys intact. 
An occasional trace of albumin in a man over forty, with or without a few 
hyaline casts, and with increased tension and thick vessel walls, usually 
indicates changes in the kidneys. The persistence of a slight amount of 
albumin in young men without increased arterial tension is less serious, 
as even after continuing for years it may disappear. I have already spoken 
of the outlook in the so-called cyclic albuminuria. 

Practically in all cases the presence of albumin indicates a change of 
some sort in the glomeruli, the nature, extent, and gravity of which it is 
difficult to estimate; so that other considerations, such as the presence of 
tube-casts, the existence of increased tension, the general condition of the 
patient, and the influence of digestion upon the albumin, must be carefully 
considered. 

The physician is daily consulted as to the relation of albuminuria and 
life assurance. As his function is to protect the interests of the company, 
he should reject all cases in which albumin occurs in the urine. It is even 
doubtful if an exception should be made in young persons with transient 
albuminuria. Naturally, companies lay great stress upon the presence or 
absence of albumin, but in the most serious and fatal malady with which 
they have to deal — chronic interstitial nephritis — the albumin is often ab- 
sent or transient, even when the disease is well developed. After the forti- 
eth year, from a standpoint of life insurance, the state of the arteries is far 
more important than the condition of the urine. 

With reference to the significance of albuminuria in adults, I quite 
agree with the following conclusions of F. C. Shattuck: 

(1) Renal albuminuria, as proved by the presence of both albumin and 
casts, is much more common in adults, quite apart from Bright's disease 
or any obvious source of renal irritation, than is generally supposed. 

(2) The frequency increases steadily and progressively with advancing 

age. 

(3) This increase with age suggests the explanation that the albumi- 
nuria is often an indication of senile degeneration. 

(4) Though it cannot be regarded as yet as absolutely proved, it is 
highly probable that faint traces of albumin and hyaline and finely granu- 
lar casts of small diameter are often, especially in those past fifty years of 
age, of little or no practical importance. 

5. Pyueia (Pus in the Urine). 

Causes. — (1) Pyelitis and Pyelonephritis. — In large abscesses of the kid- 
ney, pyonephrosis, the pus may be intermittent, while in calculous and 
tuberculous pyelitis the pyuria is usually continuous, though varying in 
intensity. In cases due to the colon or tubercle bacillus the urine is acid, 
in those due to the proteus bacillus alkaline, while in the staphylococcus 
cases the urine is either less acid than normal, or alkaline. In the pyelitis 
and pyelonephritis following cystitis the urine is alkaline or acid, depend- 



ANOMALIES OF THE URINARY SECRETION. 



859 



ing upon the infecting micro-organism; more mucus, frequent micturi- 
tion, and a previous bladder history are aids in diagnosis. 

(2) Cystitis. — The urine is usually acid, especially in women, since 
the colon bacillus is a very common cause of these infections. The pus 
and mucus are more ropy, and triple phosphate crystals are found in the 
freshly passed urine in the alkaline infections. 

(3) Urethritis, particularly gonorrhoea. The pus appears first, is in 
small quantities, and there are signs of local inflammation. 

(4) In leucorrhcea the quantity of pus is usually small, and large flakes 
of vaginal epithelium are numerous. In doubtful cases, when leucorrhcea 
is present, the urine should be withdrawn through a catheter. 

(5) Rupture of Abscesses into the Urinary Passages. — In such cases as 
pelvic or perityphlitic abscess there have been previous symptoms of pus 
formation. A large amount is passed within a short time, then the dis- 
charge stops abruptly or rapidly diminishes within a few days. 

Pus gives to the urine a white or yellowish-white appearance. On set- 
tling, the sediment is sometimes ropy, the supernatant fluid usually turbid. 
In cases due to urea-decomposing microbes (proteus bacillus, various 
staphylococci) the odor may be ammoniacal even in fresh urine. Examina- 
tion with the microscope reveals the presence of a large number of pus- 
corpuscles, which are usually, when the pus comes from the bladder, well 
formed; the protoplasm is granular, and often shows many translucent 
processes. 

The only sediment likely to be confounded with pus is that of the 
phosphates; but it is whiter and less dense, and is distinguished immedi- 
ately by microscopical examination or by the addition of acid. 

With the pus there is always more or less epithelium from the bladder 
and pelves of the kidneys, but since in these situations the forms of cells 
are practically identical, they afford no information as to the locality from 
which the pus has come. 

The treatment of pus in the urine is considered under the conditions 
in which it occurs. 

6. Chyluria — Non-parasitic. 

This is a rare affection, occurring in temperate regions and unassoci- 
ated with the Filaria bancrofti. The urine is of an opaque white color; 
it resembles milk closely, is occasionally mixed with blood (hcematochy- 
luria), and sometimes coagulates into a firm, jelly-like mass. In other 
instances there is at the bottom of the vessel a loose clot which may be 
distinctly blood-tinged. Under the microscope the turbidity seems to be 
caused by numerous minute granules — more rarely oil droplets similar to 
those of milk. In Montreal I made the dissection of a case of thirteen years' 
duration and could find no trace of parasites. 

7. Lithuria (Lithcemia; Lithic-acid Diathesis). 

The general relations of uric acid have already been considered in speak- 
ing of gout. 



860 



DISEASES OF THE KIDNEYS. 



Occurrence in the Urine. — The uric acid occurs in combination chiefly 
with ammonium and sodium, forming the acid urates. In smaller quan- 
tities are the potassium, calcium, and lithium salts. The uric acid may 
be separated from its bases and crystallizes in rhombs or prisms, which 
are usually of a deep red color, owing to the staining of the urinary pig- 
ments. The sediment formed is granular and the groups of crystals look 
like grains of Cayenne pepper. It is very important not to mistake a de- 
posit of uric acid for an excess. The deposition of numerous grains in the 
urine within a few hours after passing is more likely to be due to condi- 
tions which diminish the solvent power than to increase in the quantity. 
Of the conditions which cause precipitation of the uric acid Roberts gives 
the following: " (1) High acidity; (2) poverty in mineral salts; (3) low 
pigmentation; and (4) high percentage of uric acid." The grade of acid- 
ity is probably the most important element. 

In health the weight of uric acid excreted bears a fairly constant ratio 
to the weight of urea eliminated. According to von Noorden, the average 
ratio is 1 to 50, while the average ratio of the nitrogen of uric acid to the 
total nitrogen eliminated in the urine is 1 to 70. In several of the cases 
of gout in my wards Futcher found that in the intervals between the acute 
arthritic attacks the uric acid was reduced to a much greater extent than 
the urea, so that the ratio of the former to the latter often varied between 
1 to 300 up to (in one case) 1 to 1,500, a return to about the normal propor- 
tions occurring during the acute attacks. 

More common is the precipitation of amorphous urates, forming the 
so-called brick-dust or lateritious deposit, which has a pinkish color, due 
to the presence of urinary pigment. It is composed chiefly of the acid 
sodium urates. It occurs particularly in very acid urine of a high specific 
gravity. As the urates are more soluble in warm solutions, they frequently 
deposit as the urine cools. Here, too, the deposition does not necessarily, 
indeed usually does not, mean an excessive excretion, but the existence of 
conditions favoring the deposit. 

Lithcemia. — In addition to what has already been said under gout, we 
may consider here the hypothetical condition known as lithamiia, or the 
uric-acid diathesis. Murchison introduced the term to designate certain 
symptoms due, as he supposed, to functional disturbance of the liver. Not 
only have his views been widely adopted, but, as is so often the case when 
we give the rein to theoretical conceptions of disease, the so-called mani- 
festations of this state have so multiplied that some authors attribute to 
this cause a considerable proportion of the ailments affecting the various 
systems of the body. Thus one writer enumerates not fewer than thirty- 
nine separate morbid conditions associated with lithamiia! From our lack 
of knowledge of the mode of formation and elimination of uric acid it is 
very evident that the physiology of the subject must be widely extended 
before we are in a position to draw safe conclusions. Thus it is by no 
means sure that, as Murchison supposed, the essential defect is in a func- 
tional disorder of the liver, disturbing the metabolism of the albuminous 
ingredients, nor is it at all certain that the only offending substance is uric 
acid. In the present imperfect state of knowledge it is impossible with 



ANOMALIES OF THE URINARY SECRETION. 



861 



any clearness to define the pathology of the so-called nric-acid diathesis. 
We may say that certain symptoms arise in connection with defective food 
or tissue metabolism, more particularly of the nitrogenous elements. De- 
ficient oxidation is probably the most essential factor in the process, with 
the result of the formation of less readily soluble and less readily eliminated 
products of retrograde metamorphosis. This faulty metabolism if long 
continued may lead to gout, with uratic deposits in the joints, acute in- 
flammations, and arterial and renal disease. In a large group of cases the 
disturbed metabolism produces high tension in the arteries (probably as a 
direct sequence of interference with the capillary circulation) and ulti- 
mately degenerations in various tissues, particularly the scleroses. 

Overeating and overdrinking, when combined with deficient muscular 
exercise, lie at the basis of this nutritional disturbance. The symptoms 
which are believed to characterize the uric-acid diathesis have already been 
briefly treated of under the section on irregular gout, and the question of 
diet and exercise has also been there considered. 

8. OXALUEIA. 

The discovery of calcium-oxalate crystals in the urine by Donne in 1838 
led to the description of the so-called oxalic-acid diathesis. It is claimed 
that all the oxalic acid found in the urine is taken into the body with the 
food (Dunlop). In health none, or only a trace, is formed in the body. The 
amount fluctuates with the quantity of food taken, and is usually below 10 
milligrammes daily (H. Baldwin). It seems to be formed in the body when 
there is an absence of free hydrochloric acid in the gastric juice, and in 
connection with excessive fermentation in the intestines. It never forms 
a heavy deposit, but the crystals — usually octahedral, rarely dumb-bell- 
shaped — collect in the mucus-cloud and on the sides of the vessel. 

When in excess and present for any considerable time, the condition is 
kown as oxaluria, the chief interest of which is in the fact that the crys- 
tals may be deposited before the urine is voided, and form a calculus. It 
is held by many that there is a special diathesis associated with its presence 
in excess and manifested clinically by dyspepsia, particularly the nervous 
form, irritability, depression of spirits, lassitude, and sometimes marked 
hypochondriasis. There may be in addition neuralgic pains and the gen- 
eral symptoms of neurasthenia. The local and general symptoms ace prob- 
ably dependent upon some disturbance of metabolism of which the oxaluria 
is one of the manifestations. It is a feature also in many gouty persons, 
and in the condition called lithaemia. 

9. Cystinuria. 

Stadthagen claims that normal urine does not contain cystin, though 
Baumann and Goldmann succeeded in separating it in very small quan- 
tities from healthy urine as a benzoyl compound. It is associated with 
elimination of diamines both in the fa?ces and urine. It is very rarely met 



862 



DISEASES OF THE KIDNEYS. 



with, and its chief interest is owing to the fact that it may form a calcu- 
lus. Its presence in the urine has been determined in many members of 
the same family, and the condition appears sometimes to be hereditary. 
As it contains sulphur, it is thought to be formed from the taurin of the 
bile. 

10. Phosphatueia. 

The phosphoric acid is excreted from the body in combination with 
potassium, sodium, calcium, and magnesium, forming two classes, the alka- 
line phosphates of sodium and potassium and the earthy phosphates of 
lime and magnesia. The amount of phosphoric acid (P 2 0 5 ) excreted in the 
twenty-four hours varies, according to Hammarsten, between 1 and 5 
grammes, with an average of 2.5 grammes. It is derived mainly from the 
phosphoric acid taken in the food, but also in part as a decomposition prod- 
uct from nuclein, protagon, and lecithin. Of the alkaline phosphates, those 
in combination with sodium are the most abundant. The alkaline phos- 
phates of the urine are more abundant than the earthy phosphates. 

Of the earthy phosphates, those of lime are abundant, of magnesium 
scanty. In urine which has undergone the ammoniacal fermentation, either 
inside or outside the body, there is in addition the ammonio-magncsium 
or triple phosphate, which occurs in triangular prisms or in feathery or 
stellate crystals; hence the term given to this form of stellar phosphates. 
The earthy phosphates occur as a sediment in the urine when the alka- 
linity is due to a fixed alkali, or under certain circumstances the deposit 
may take place within the bladder, and then the phosphates are passed 
at the end of micturition as a whitish fluid, which is popularly confounded 
with spermatorrhoea. The calcium phosphate may be precipitated by heat 
and produce a cloudiness which may be mistaken for albumin, but is at 
once dissolved upon making the urine acid. This condition is very fre- 
quent in persons suffering from dyspepsia or from debility of any kind. 
The phosphates may be in great excess, rising in the twenty-four hours to 
from 7 to 9 grammes (Tessier), whereas the normal amount is not more 
than 2.5 grammes. And, lastly, the phosphates may be deposited in urine 
which has undergone decomposition, in which the carbonate of ammonia 
from the urea combines with the magnesium phosphates, forming the triple 
salt. This is seen in cystitis, due to a urea-decomposing microbe. 

The clinical significance of an excess of phosphates, to which the term 
phosphaturia is applied, has been much discussed. It must be remem- 
bered that a deposit does not necessarily mean an excess, to determine 
which a careful analysis of the twenty-four hours' secretion should be made. 
It has long been thought that there is a relation between the activity of 
the nerve-tissues and the output of phosphoric acid; but the question can 
not yet be considered settled. The amount is increased in wasting dis- 
eases, such as phthisis, acute yellow atrophy of the liver, leukaemia, and 
severe anaemia, whereas it is diminished in acute diseases and during 
pregnancy. 

In a condition termed by Tessier, Ealfe, and others, phosphatic dia- 
betes there are polyuria, thirst, emaciation, and a great increase in the 



ANOMALIES OF THE URINARY SECRETION. 



863 



excretion of phosphates, which may be as much as from 7 to 9 grammes in 
the day. The urine is usually acid and free from sugar; the patients are 
nervous; in some instances sugar has been present in the urine, and in 
others it subsequently makes its appearance. 

11. InDICANTJKIA. 

The substance in the urine which has received this name is the indoxyl- 
sulphate of potassium, in which form it appears in the urine and is color- 
less. When concentrated acids or strong oxidizing agents are added to 
the urine, this substance is decomposed and the indigo set free. It is pres- 
ent only in small quantities in healthy urine. It is derived from the indol, 
a product formed in the intestine by the decomposition of the albumin 
under the influence of bacteria. When absorbed, this is oxidized in the 
tissues to indoxyl, which combines with the potassium sulphate, forming 
the above-named substance. 

The quantity of indican is diminished on a milk (and a Kefir) diet. 
It is increased in all wasting diseases, as carcinoma, and whenever any 
large quantities of albuminous substances are undergoing rapid decompo- 
sition, as in the severer forms of peritonitis and empyema. It is not usually 
increased in constipation, but is met with in ileus, particularly in obstruc- 
tion of the small intestine. Indican has occasionally been found in calculi. 
Though, as a rule, the urine is colorless when passed, there are instances 
in which the decomposition has taken place within the body, and a blue 
color has been noticed immediately after the urine was voided. Sometimes, 
too, in alkaline urine on exposure there is a bluish film on the surface. 

To test for indican, place 4 or 5 cc. of nitric or hydrochloric acid in a 
test-tube; boil, and add an equal quantity of urine. A bluish ring develops 
at the point of contact. Add 1 or 2 cc. of chloroform and shake the test- 
tube; on separation the chloroform has a violet or bluish color due to the 
presence of indican. 

12. Melanueia. 

In melanotic cancer the urine, either at the time of voiding or after 
exposure to the air, may present a dark color. This pigment is known as 
melanin, and it may occur in solution or in the form of small granules. 
The urine may be voided clear, and subsequently, on exposure to the air 
or on the addition of oxidizing substances, becomes dark. In these cases 
it contains a chromogen called melanogen, which turns dark by oxidation. 
Von Jaksch has found that "in urine containing melanin or its precursor, 
melanogen, Prussian blue is formed by adding a nitroprusside, aqueous 
potash, and an acid. This reaction, however, does not seem to depend on 
the presence of melanin, as it is not given by that substance when sep- 
arated from the urine, but apparently by some other at present unknown 
substance, which is present in traces in normal urine and is increased in 
cases of melanuria, and also in those conditions where excess of indigo 
occurs in the urine " (Halliburton). 



864: 



DISEASES OF THE KIDNEYS. 



13. Pneumaturia. 
Gas may be passed with the urine — 

1. After mechanical introduction of air in vesical irrigation or cysto- 
scopic examination in the knee-elbow position. 

2. As a result of the introduction of gas-forming organisms in catheter- 
ization or other operation. Glycosuria has been present in a majority of 
the cases. The yeast fungus, the colon bacillus, and the bacillus aerogenes 
capsulatus have been found. 

3. In cases of vesico-enteric fistula. 

In gas production within the bladder the symptoms are those of a mild 
cystitis, with the passage of gas at the end of micturition, sometimes with 
a loud sound. The diagnosis is readily made by causing the patient to 
urinate in a bath or by plunging the end of the catheter under water. 

14. Other Substances. 

Fat in the urine, or lipuria, occurs, according to Halliburton, first, with- 
out disease of the kidneys, as in excess of fat in the food, after the admin- 
istration of -cod-liver oil, in fat embolism occurring after fractures, in the 
fatty degeneration in phosphorus poisoning, in prolonged suppuration, as 
in phthisis and pyaemia, in the lipaemia of diabetes mellitus; secondly, with 
disease of the kidneys, as in the fatty stage of chronic Bright's disease, in 
which fat casts are sometimes present, and, according to Ebstein, in pyo- 
nephrosis; and, thirdly, in the affection known as chyluria. The urine 
is usually turbid, but there may be fat drops as well, and fatty crystals have 
been found. 

Lipaciduria is a term applied by von Jaksch to the condition in which 
there are volatile fatty acids in the urine, such as acetic, butyric, formic, 
and propionic acid. 

Acetonuria. — Von Jaksch distinguishes the following forms of patho- 
logical acetonuria: The febrile, the diabetic, the acetonuria with certain 
forms of cancer, the form associated with inanition, acetonuria in psychoses, 
and the acetonuria which results from auto-intoxication. It is doubtful, 
however, whether the symptoms in these are really due to the acetone. It 
may be the substances from which this is formed, particularly the diacetic 
acid or the /3-oxy-butyric acid. The odor of the acetone may be marked 
in the breath and evident in the urine. The tests have been given in the 
section on diabetes. 

Diacetic acid is probably never present in the urine in health. With 
a solution of ferric chloride it gives a Burgundy-red color. A similar re- 
action is given by acetic, formic, and oxy-butyric acids; it may be present 
in the urine of patients who are taking antipyrin, thallin, and the sali- 
cylates. Hammarsten states that if the reaction be due to the presence of 
diacetic acid, it will not be obtained in carrying out the test with a second 
specimen of urine which has been boiled and allowed to cool. The ethereal 
extract of the acidulated urine gives the reaction if diacetic acid be present, 
whereas the other substances which may be mistaken for diacetic acid are 
insoluble in ether. 



URiEMIA. 



865 



/?-oxy-butyric acid is believed by Stadelmann, Kiilz, and Minkowski to 
be the cause of diabetic coma. It is a product of the decomposition of the 
tissue albumins, and from it diacetic acid is readily formed by oxidation. 
Its tests have already been given. 

Alcaptonuria. — Aromatic compounds occur after the administration of 
carbolic acid or gallic acid, and the urine on exposure to air becomes dark. 
In carboluria the substance causing the black color is known as hydro- 
chinon. Many years ago Boedeker met with cases in which the urine be- 
came dark, owing to the presence of an aromatic compound which he called 
alcapton. The urine is clear on passing, and then darkens on exposure to 
the air, or on the addition of liquor potassae. Baumann isolated a substance 
from the urine of a case of alcaptonuria, to which he gave the name of 
homogentisinic acid. Later observers have isolated this substance in other 
cases. Kirk believed the reaction in his case was due to uroleucinic acid. 
In several instances more than one member of a family has shown this 
urinary change. The substance is apparently without clinical significance 
except in so far as it is capable of reducing the Fehling solution, and may 
be mistaken for sugar. Alcapton urine may be distinguished from diabetic 
urine from the fact that it does not ferment nor reduce alkaline bismuth 
solutions, and because it is optically inactive (see Alcaptonuria, by T. B. 
Futcher, New York Med. Jour., 1897, ii). 

Choluria and glycosuria have already been considered under jaundice 
and diabetes. 

Kodmato porphyrin occasionally occurs in the urine. It was first recog- 
nized by Hoppe-Seyler. Nencki and Sieler determined its exact formula, 
and the former demonstrated that the only chemical difference between 
haematin and haematoporphyrin is that the latter is simply haematin fiee 
from iron. It has been found in the urine in pulmonary tuberculosis, 
pleurisy with effusion, acute rheumatism, lead poisoning, and intestinal 
haemorrhages. This pigment has been found very frequently after the ad- 
ministration of sulphonal, and sometimes imparts a very dark color to the 
urine. 

V. URAEMIA. 

Definition. — A toxaemia developing in the course of nephritis or in 
conditions associated with anuria. The nature of the poison or poisons is 
as yet unknown, whether they are the retained normal products or the 
products of an abnormal metabolism. 

Theories of Uraemia. — The view most widely held is that uraemia 
is due to the accumulation in the blood of excrementitious material — body 
poisons — which should be thrown off by the kidneys. " If, however, from 
any cause, these organs make default, or if there be any prolonged obstruc- 
tion to the outflow of urine, accumulation of some or of all the poisons 
takes place, and the characteristic symptoms are manifested, but the ac- 
cumulation may be very slow and the earlier symptoms, corresponding to 
the comparatively small dose of poison, may be very slight; yet they are in 
kind, though not in degree, as indicative of uraemia as are the more alarm- 



866 



DISEASES OP THE KIDNEYS. 



ing, which appear toward the end, and to which alone the name uraemia is 
often given " (Carter). Herter and others have shown that the toxicity of 
the blood-serum in ursemic states is increased. The part played by urea 
itself, by the salts, and by the nitrogenous extractives has not been deter- 
mined. 

Another view is that uraemia depends on the products of an abnormal 
metabolism. Brown-Sequard suggested that the kidney has an internal 
secretion, and it is urged that the symptoms of uraemia are due to its dis- 
turbance. Bradford's experiments show that the kidneys do influence pro- 
foundly the metabolism of the tissues of the body, particularly of the mus- 
cles. If more than one third of the total kidney weight be removed, there 
is an extraordinary increase in the production of urea and of the nitrogenous 
bodies of the creatin class. He favors this view, but acknowledges that we 
are still ignorant of the nature of the poison. From a careful study of the 
question, Hughes and Carter concluded that the poison was an albuminous 
product quite different from anything in normal urine. In Bradford's (loul- 
stonian Lectures (1898) will be found a full discussion of the question. 

Traube believed that the symptoms of uraemia, particularly the coma 
and convulsions, were due to localized oedema of the brain. 

Symptoms. — Clinically, we may recognize latent, acute, and chronic 
forms of uraemia. The latent form has been considered under the section 
on anuria. Acute uraemia may develop in any form of nephritis. It is 
more common in the post-febrile varieties. Bradford thinks that it is spe- 
cially associated with a form of contracted white kidney in young subjects. 
Chronic forms of uraemia are more frequent in the arterio-sclerotic and 
granular kidney. For convenience the symptoms of uraemia may be de- 
scribed under cerebral, dyspnoeic, and gastro-intestinal manifestations. 

Among the cerebral symptoms of uraemia may be described: 

(a) Mania. — This may come on abruptly in an individual who has 
shown no previous indications of mental 'trouble, and who may not be 
known to have Bright' s disease. In a remarkable case of this kind which 
came under my observation the patient became suddenly maniacal and died 
in six days. More commonly the delirium is less violent, but the patient 
is noisy, talkative, restless, and sleepless. 

(b) Delusional Insanity (Folie Briglitique). — Cases are by no means un- 
common, and excellent clinical reports have been issued on the subject 
from several of the asylums of this country, particularly by Bremer, Chris- 
tian, and Alice Bennett. Delusions of persecution are common. One of 
my cases committed suicide by jumping out of a window. The condition 
is of interest medico-legally because of its bearing on testamentary capacity. 
Profound melancholia may also supervene. 

(c) Convulsions. — These may come on unexpectedly or be preceded by 
pain in the head and restlessness. The attacks may be general and iden- 
tical with those of ordinary epilepsy, though the initial cry may not be 
present. The fits may recur rapidly, and in the interval the patient is 
usually unconscious. Sometimes the temperature is elevated, but more 
frequently it is depressed, and may sink rapidly after the attack. Local 
or Jacksonian epilepsy may occur in most characteristic form in uraemia. 



UBJEMIA. 



867 



A remarkable sequence of the convulsions is blindness — urcemic amaurosis 
— which may persist for several days. This, however, may occur apart from 
the convulsions. It usually passes off in a day or two. There are, as a rule, 
no ophthalmoscopic changes. Sometimes uremic deafness supervenes, and 
is probably also a cerebral manifestation. It may also occur in connection 
with persistent headache, nausea, and other gastric symptoms. 

(d) Coma. — Unconsciousness invariably accompanies the general con- 
vulsions, but a coma may develop gradually without any convulsive seizures. 
Frequently it is preceded by headache, and the patient gradually becomes 
dull and apathetic. In these cases there may have been no previous indi- 
cations of renal disease, and unless the urine is examined the nature of the 
case may be overlooked. Twitchings of the muscles occur, particularly in 
the face and hands, but there are many cases of coma in which the muscles 
are not involved. In some of these cases a condition of torpor persists for 
weeks or even months. The tongue is usually furred and the breath very 
foul and heavy. 

(e) Local Palsies. — In the course of chronic Bright's disease hemiplegia 
or monoplegia may come on spontaneously or follow a convulsion, and post 
mortem no gross lesions of the brain be found, but only a localized or dif- 
fused oedema. These cases, which are not very uncommon, may simulate 
almost every form of organic paralysis of cerebral origin. 

(/) Of other cerebral symptoms, headache is important. It is most 
often occipital and extends to the neck. It may be an early feature and 
associated with giddiness. Other nervous symptoms of uraemia are intense 
itching of the skin, numbness and tingling in the fingers, and cramps in 
the muscles of the calves, particularly at night. An erythema may be 
present. 

Urcemic dyspnoea is classified by Palmer Howard as follows: (1) Con- 
tinuous dyspnoea; (2) paroxysmal dyspnoea; (3) both types alternating; and 
(4) Cheyne-Stokes breathing. The attacks of dyspnoea are most commonly 
nocturnal; the patient may sit up, gasp for breath, and evince as much 
distress as in true asthma. Occasionally the breathing is noisy and stridu- 
lus. The Cheyne-Stokes type may persist for weeks, and is not necessarily 
associated with coma. I have seen it in a man who travelled over a hun- 
dred miles to consult a physician. In another instance a patient, up and 
about, could only when at meals feed himself in the apncea period. Though 
usually of serious omen and occurring with coma and other symptoms, re- 
covery may follow even after persistence for weeks or even months. 

The g astro-intestinal manifestations of uraemia often set in with abrupt- 
ness. Uncontrollable vomiting may come on and its cause be quite un- 
recognizable. A young married woman was admitted to my wards in the 
Montreal General Hospital with persistent vomiting of four or five days' 
duration. The urine was slightly albuminous, but she had none of the 
usual signs of uraemia, and the case was not regarded as one of Bright's 
disease. The vomiting persisted and caused death. The post mortem 
showed extensive sclerosis of both kidneys. The attacks may be preceded 
by nausea and may be associated with diarrhoea. In some instances the 
diarrhoea may come on without the vomiting; sometimes it is profuse and 



868 



DISEASES OF THE KIDNEYS. 



associated with an intense catarrhal or even diphtheritic inflammation of 
the colon. 

A special uraemic stomatitis has been described (Barie) in which the 
mucosa of the lips, gums, and tongue is swollen and erythematous. The 
saliva may be increased, and there is difficulty in swallowing and in mastica- 
tion. The tongue is usually very foul and the breath heavy and fetid. A 
cutaneous erythema may occur and a remarkable urea " frost " on the skin. 

Fever is not uncommon in uraemic states, and may occur with the acute 
nephritis, with the complications, and as a manifestation of the uraemia 
itself (Stengel). 

Very many patients with chronic uraemia succumb to what I have called 
terminal infections — acute peritonitis, pericarditis, pleurisy, meningitis, or 
endocarditis. 

Diagnosis. — Herter calls attention to the value of the clinical deter- 
mination of the urea in the blood (for which purpose only a few cubic centi- 
metres are required) as an index of the degree of renal inadequacy. So far 
as the urine is concerned, the volume and specific gravity indicate the total 
solids, and the determination of the urea itself in the urine gives no indica- 
tion of the quantity in the blood. Uraemia may be confounded with: 

(a) Cerebral lesions, such as haemorrhage, meningitis, or even tumor. 
In apoplexy, which is so commonly associated with kidney disease and 
stiff arteries, the sudden loss of consciousness, particularly if with convul- 
sions, may simulate a uraemic attack; but the mode of onset, the existence 
of complete hemiplegia, with conjugate deviation of the eyes, suggest 
haemorrhage. As already noted, there are cases of uraemic hemiplegia or 
monoplegia which cannot be separated from those of organic lesion and 
which post mortem show no trace of coarse disease of the brain. I know 
of an instance in which a consultation was held upon the propriety of opera- 
tion in a case of hemiplegia believed to be due to subdural haemorrhage 
which post mortem was shown to be uraemic. Indeed, in some of these cases 
it is quite impossible to distinguish between the two conditions. So, too, 
cases of meningitis, in a condition of deep coma, with perhaps slight fever, 
furred tongue, but without localizing symptoms, may readily be confounded 
with uraemia. 

(b) With certain infectious diseases. Uraemia may persist for weeks 
or months and the patient lies in a condition of torpor or even uncon- 
sciousness, with a heavily coated, perhaps dry, tongue, muscular twitchings, 
a rapid feeble pulse, with slight fever. This state not unnaturally suggests 
the existence of one of the infectious diseases. Cases of the kind are not 
uncommon, and I have known them to be mistaken for typhoid fever and 
for miliary tuberculosis. 

(c) Uraemic coma may be confounded with poisoning by alcohol or 
opium. In opium poisoning the pupils are contracted; in alcoholism they 
are more commonly dilated. In uraemia they are not constant; they may 
be either widely dilated or of medium size. The examination of the eye- 
ground should be made to determine the presence or absence of albuminuric 
retinitis. The urine should be drawn off and examined. The odor of the 
breath sometimes gives an important hint. 



ACUTE BRIGHT'S DISEASE. 



869 



The condition of the heart and arteries should also be taken into ac- 
count. Sudden uraemic coma is more common in the chronic interstitial 
nephritis. The character of the delirium in alcoholism is sometimes im- 
portant, and the coma is not so deep as in uraemia or opium poisoning. 
It may for a time be impossible to determine whether the condition is 
due to uraemia, profound alcoholism, or haemorrhage into the pons Varolii. 

And lastly, in connection with sudden coma, it is to be remembered 
that insensibility may occur after prolonged muscular exertion, as after 
running a ten-mile race. In some instances unconsciousness has ccme on 
rapidly with stertorous breathing and dilated pupils. Cases have occurred 
under conditions in which sun-stroke could be excluded; and Poore, who 
reports a case in the Lancet (1894), considers that the condition is due to 
the too rapid accumulation of waste products in the blood, and to hyper- 
pyrexia from suspension of sweating. 

The treatment will be considered under Chronic Bright's Disease. 



VI. ACUTE BRIGHT'S DISEASE. 

Definition. — Acute diffuse nephritis, due to the action of cold or of 
toxic agents upon the kidneys. 

In all instances changes exist in the epithelial, vascular, and inter- 
tubular tissues, which vary in intensity in different forms; hence writers 
have described a tubular, a glomerular, and an acute interstitial nephritis. 
Delafield recognizes acute exudative and acute productive forms, the latter 
characterized by proliferation of the connective-tissue stroma and of the 
cells of the Malpighian tufts. 

Etiology. — The following are the principal causes of acute nephritis: 

(1) Cold. Exposure to cold and wet is one of the most common causes. 
It is particularly prone to follow exposure after a drinking-bout. 

(2) The poisons of the specific fevers, particularly scarlet fever, less 
commonly typhoid fever, measles, diphtheria, small-pox, chicken-pox, ma- 
laria, cholera, yellow fever, meningitis, and, very rarely, dysentery. Acute 
nephritis may be associated with syphilis and with acute tuberculosis. It 
may also occur in septicaemia and in acute tonsillitis. In exudative ery- 
thema and the allied purpuric affections acute nephritis is not uncommon. 
Among 1,832 cases of malaria at the Johns Hopkins Hospital there were 
26 of nephritis (Thayer). 

(3) Toxic agents, such as turpentine, cantharides, potassium chlorate, 
and carbolic acid may cause an acute congestion which sometimes ter- 
minates in nephritis. Alcohol probably never excites an acute nephritis. 

(4) Pregnancy, in which the condition is thought by some to result 
from compression of the renal veins, although this is not yet finally settled. 
The condition may in reality be due to toxic products as yet undetermined. 

(5) Acute nephritis occurs occasionally in connection with extensive 
lesions of the skin, as in burns or in chronic skin-diseases, and also after 
trauma. It may follow operations on the kidney. 

Morbid Anatomy. — The kidneys may present to the naked eye in 
mild cases no evident alterations. When seen early in more severe forms 



870 



DISEASES OF THE KIDNEYS. 



the organs are congested, swollen, dark, and on section may drip blood. 
In other instances the surface is pale and mottled, the capsule strips off 
readily, and the cortex is swollen, turbid, and of a grayish-red color, while 
the pyramids have an intense beefy-red tint. The glomeruli in some in- 
stances stand out plainly, being deeply swollen and congested; in other 
instances they are pale. 

The histology may be thus summarized: (a) Glomerular changes. In 
a majority of* the cases of nephritis due to toxic agents, which reach the 
kidney through the blood-vessels, the tufts suffer first, and there is either 
an acute intracapillary giomerulitis, in which the capillaries become 1 filled 
with cells and thrombi, or involvement of the epithelium of the tuft and 
of Bowman's capsule, the cavity of which contains leucocytes and red 
blood-corpuscles. Hyaline degeneration of the contents and of the walls 
of the capillaries of the tuft is an extremely common event. These pro- 
cesses are perhaps best marked in scarlatinal nephritis. There may be 
proliferation about Bowman's capsule. These changes interfere with the 
circulation in the tufts and seriously influence the nutrition of the tubular 
structures beyond them. 

(b) The alterations in the tubular epithelium consist in cloudy swelling, 
fatty change, and hyaline degeneration. In the convoluted tubules, the 
accumulation of altered cells with leucocytes and blood-corpuscles causes 
the enlargement and swelling of the organ. The epithelial cells lose their 
striation, the nuclei are obscured, and hyaline droplets often accumulate 
in them. 

(c) Interstitial changes. In the milder forms a simple inflammatory 
exudate — serum mixed with leucocytes and red blood-corpuscles — exists 
between the tubules. In severer cases areas of small-celled infiltration 
occur about the capsules and between the convoluted tubes. These changes 
may be widespread and uniform throughout the organs or more intense 
in certain regions. 

Councilman has described an acute interstitial nephritis occurring chiefly 
in children after fevers, characterized by the presence of cells similar to 
those described by Unna as plasma cells. He thinks that these cells are 
formed in other organs, chiefly the spleen and bone marrow, and are car- 
ried to the kidneys in the blood current. 

Symptoms. — The onset is usually sudden, and when the nephritis 
follows cold, dropsy may be noticed within twenty-four hours. After fevers 
the onset is less abrupt, but the patient gradually becomes pale and a puffi- 
ness of the face or swelling of the ankles is first noticed. In children there 
may at the outset be convulsions. Chilliness or rigors initiate the attack 
in a limited number of cases. Pain in the back, nausea, and vomiting may 
be present. The fever is variable. Many cases in adults have no rise in 
temperature. In young children Avith nephritis from cold or scarlet fever 
the temperature may, for a few days, range from 101° to 103°. 

The most characteristic symptoms are the urinary changes. There may 
at first be suppression; more commonly the urine is scanty, highly colored, 
and contains blood, albumin, and tube-casts. The quantity is reduced and 
only 4 or 5 ounces may be passed in the twenty-four hours; the specific 



ACUTE BRIGHT'S DISEASE. 



871 



gravity is high — 1.025, or even more; the color varies from a smoky to a 
deep porter color, but is seldom bright red. On standing there is a heavy 
deposit; microscopically there are blood-corpuscles, epithelium from the 
urinary passages, and hyaline, blood, and epithelial tube-casts. The albu- 
min is abundant, forming a curdy, thick precipitate. The total excretion 
of urea is reduced, though the percentage is high. 

Anaemia is an early and marked symptom. In cases of extensive dropsy, 
effusion may take place into the pleurae and peritonaeum. There are cases 
of scarlatinal nephritis in which the dropsy of the extremities is trivial and 
effusion into the pleurae extensive. The lungs may become oedematous. In 
rare cases there is oedema of the glottis. Epistaxis may occur or cutaneous 
ecchymoses may develop in the course of the disease. 

The pulse may be hard, the tension increased, and the second sound 
in the aortic area accentuated. Occasionally dilatation of the heart comes 
on rapidly and may cause sudden death (Ooodhart). The skin is dry and 
it may be difficult to induce sweating. 

Uraemic symptoms develop in a limited number of cases. They may 
occur at the onset with suppression, more commonly later in the disease. 
Ocular changes are not so common in acute as in chronic Bright's disease, 
but haemorrhagic retinitis may occur and occasionally papillitis. 

The course of acute Bright's disease varies considerably. The descrip- 
tion just given is of the form which most commonly follows cold or scarlet 
fever. In many of the febrile cases dropsy is not a prominent symptom, 
and the diagnosis rests rather with the examination of the urine. More- 
over, the condition may be transient and less serious. In other cases, as 
in the acute nephritis of typhoid fever, there may be haematuria and pro- 
nounced signs of interference with the renal function. The most intense 
acute nephritis may exist without anasarca. 

In scarlatinal nephritis, in which the glomeruli are most seriously af- 
fected, suppression of the urine may be an early symptom, the dropsy is 
apt to be extreme, and uraemic manifestations are common. Acute Bright's 
disease in children, however, may set in very insidiously and be associated 
with transient or slight oedema, and the symptoms may point rather to 
affection of the digestive system or to brain-disease. 

Diagnosis. — It is very important to bear in mind that the most seri- 
ous involvement of the kidneys may be manifested only by slight oedema 
of the feet or puffiness of the eyelids, without impairment of the general 
health. The first indication of trouble may be a uraemic convulsion. This 
is particularly the case in the acute nephritis of pregnancy, and it is a good 
rule for the practitioner, when engaged to attend a case, invariably to ask 
that during the seventh and eighth months the urine should occasionally 
be sent for examination. 

In nephritis from cold and in scarlet fever the symptoms are usually 
marked and the diagnosis is rarely in doubt. As already mentioned, every 
case in which albumin is present must not be called acute Bright's disease, 
not even if tube-casts be present. Thus the common febrile albuminuria, 
although it represents the first link in the chain of events leading to acute 
Bright's disease, should not be placed in the same category. 



872 



DISEASES OF THE KIDNEYS. 



There are occasional cases of acute Bright' s disease with anasarca, in 
which albumin is either absent or present only as a trace. This is a rare 
condition. Tube-casts are usually found, and the absence of albumin is 
rarely permanent. The urine may be reduced in amount. 

The character of the casts is of use in the diagnosis of the form of 
Bright's disease, but scarcely of such extreme value as has been stated. 
Thus, the hyaline and granular casts are common to all varieties. The 
blood and epithelial casts, particularly those made up of leucocytes, are 
most common in the acute cases. 

Prognosis. — The outlook varies somewhat with the cause of the dis- 
ease. Eecoveries in the form following exposure to cold are much more 
frequent than after scarlatinal nephritis. In young children the mortality 
is high, amounting to at least one third of the cases. Serious symptoms 
are low arterial tension, the occurrence of uraemia, and effusion into the 
serous sacs. The persistence of the dropsy after the first month, intense 
pallor, and a large amount of albumin indicate the possibility of the dis- 
ease becoming chronic. For some months after the disappearance of the 
dropsy there may be traces of albumin and a few tube-casts. 

In a week or ten days, in a case of scarlatinal nephritis, if the progress 
is favorable, the dropsy diminishes, the urine increases, the albumin lessens, 
and by the end of a month the dropsy has disappeared and the urine is 
nearly free. In very young children the course may be rapid, and I have 
known the urine to be free from albumin in the fourth week. Other cases 
are more insidious, and though the dropsy may disappear, the albumin per- 
sists in the urine, the anaemia is marked, and the condition becomes chronic, 
or, after several recurrences of the dropsy, improves and complete recovery 
takes place. 

Treatment. — The patient should be in bed and there remain until 
all traces of the disease have disappeared. As sweating plays such an im- 
portant part in the treatment, it is well, if possible, to accustom the patient 
to blankets. He should also be clad in thin Canton flannel. 

The diet should consist of milk or butter-milk, gruels made of arrow- 
root or oat-meal, barley water, and, if necessary, beef tea and chicken broth. 
It is better, if possible, to confine the patient to a strictly milk diet. As 
convalescence is established, bread and butter, lettuce, water-cress, grapes, 
oranges, and other fruits may be given. The return to a meat diet should 
be gradual. 

The patient should drink freely of alkaline mineral waters, ordinary 
water, or lemonade. The fluids keep the kidneys flushed and wash out the 
debris from the tubes. A useful drink is a drachm of cream of tartar in a 
pint of boiling water, to which may be added the juice of half a lemon and 
a little sugar. Taken when cold, this is a pleasant and satisfactory diluent 
drink. 

No remedies, so far as known, control directly the changes which are 
going on in the kidneys. The indications are: (1) To give the excretory 
function of the kidney rest by utilizing the skin and the bowels, in the hope 
that the natural processes may be sufficient to effect a cure; (2) to meet 
the symptoms as they arise. 



ACUTE BRIGHT'S DISEASE. 



873 



In a case of scarlet fever it may occasionally be possible to avert an 
attack, the premonitory symptoms of which are marked increase in the 
arterial tension and the presence of blood coloring matter in the urine 
(Mahomed). An active saline cathartic may completely relieve this con- 
dition. 

At the onset, when there is pain in the back or hematuria, the Paquelin 
cautery or the dry or wet cups give relief. The last should not be used 
in children. Warm poultices are often grateful. In cases which set in 
with suppression of urine, these measures should be adopted, and in addi- 
tion the hot bath with subsequent pack, copious diluents, and a free purge. 
The dropsy is best treated by hydrotherapy — either the hot bath, the wet 
pack, or the hot-air bath. In children the wet pack is usually satisfactory. 
It is applied by wringing a blanket out of hot water, wrapping the child 
in it, covering this with a dry blanket, and then with a rubber cloth. In 
this the child may remain for an hour. It may be repeated daily. In the 
case of adults, the hot-air bath or the vapor bath may be conveniently given 
by allowing the vapor or air to pass from a funnel beneath the bed-clothes, 
which are raised on a low cradle. More efficient, as a rule, is a hot bath of 
from fifteen or twenty minutes, after which the patient is wrapped in 
blankets. The sweating produced by these measures is usually profuse, 
rarely exhausting, and in a majority of cases the dropsy can in this way be 
relieved. There are some cases, however, in which the skin does not re- 
spond to the baths, and if the symptoms are serious, particularly if uraemia 
supervenes, jaborandi or its active principle, pilocarpine, may be used. 
The latter may be given hypodermically, in doses of from a sixth to an 
eighth of a grain in adults, and from a twentieth to a twelfth of a grain in 
children from two to ten years. 

The bowels should be kept open by a morning saline purge; in children 
the fluid magnesia is readily taken; in adults the sulphate of magnesia may 
be given by Hay's method, in concentrated form, in the morning, before 
anything is taken into the stomach. In Bright' s disease it not infrequently 
causes vomiting. The compound powder of jalap, in half-drachm doses, 
or, if necessary, elaterium may be used. If the dropsy is not extreme, the 
urine not very concentrated, and ursemic symptoms are not present, the 
bowels should be kept loose without active purgation. If these measures 
fail to reduce the dropsy and it has become extreme, the skin may be punc- 
tured with a lancet or drained by a small silver canula (Southey's tube), 
which is inserted beneath it. A fine aspirator needle may be used, and the 
fluid allowed to drain through a piece of long, narrow rubber tubing into 
a vessel beneath the bed. If the dyspnoea is marked, owing to pressure of 
fluid in the pleurae, aspiration should be performed. In rare instances the 
ascites is extreme and may require paracentesis, or a Southey's tube may 
be inserted and the fluid gradually withdrawn. If uraemic convulsions 
occur, the intensity of the paroxysms may be limited by the use of chloro- 
form; to an adult a pilocarpine injection should be at once given, and 
from a robust, strong man 20 ounces of blood may be withdrawn. In chil- 
dren the loins may be dry cupped, the wet pack used, and a brisk purgative 
given. Bromide of potassium and chloral sometimes prove useful. 
54 



DISEASES OF THE KIDNEYS. 



Vomiting may be relieved by ice and by restricting the amount of food. 
Drop doses of creasote, iodine, and carbolic acid may be given. The dilute 
hydrocyanic acid with bismuth is often effectual. 

The question of the use of diuretics in acute Bright' s disease is not yet 
settled. The best diuretic, after all, is water, which may be taken freely 
with the citrate of potash or the benzoate of soda, salts which are held to 
favor the conversion of the urates into less irritating and more easily ex- 
creted compounds. Digitalis and strophanthus are useful diuretics, and 
may be employed without risk when the arterial tension is low and the car- 
diac impulse is not forcible. I have never seen any injurious effects from 
their employment after the early symptoms had lessened in intensity. 

For the persistent albuminuria, I agree with Koberts and Rosenstein 
that we have no remedy of the slightest value. Nothing indicates more 
clearly our helplessness in controlling kidney metabolism than inability to 
meet this common symptom. Astringents, alkalies, nitroglycerin, and mer- 
cury have been recommended. 

For the anamria always associated with acute Bright's disease iron should 
be employed. It should not be given until the acute symptoms have sub- 
sided. In the adult it may be used in the form of the perchloride in in- 
creasing doses, as convalescence proceeds. In children, the syrup of the 
iodide of iron or the syrup of the phosphate of iron are better preparations. 
Tyson has recently urged caution in the too free use of iron in kidney 
disease. The dilatation of the heart is best treated with digitalis, strophan- 
thus, and strychnia. 

In the convalescence from acute Bright's disease, care should be taken 
to guard the patient against cold. The diet should still consist chiefly of 
milk and a return to mixed food should be gradual. A change of air is 
often beneficial, particularly a residence in a warm, equable climate. 



VII. CHRONIC BRIGHT'S DISEASE. 

Here, too, in all forms we deal with a diffuse process, involving epi- 
thelial, interstitial, and glomerular tissues. Clinically two groups are recog- 
nized — (a) the chronic parenchymatous nephritis, which follows the acute 
attack or comes on insidiously, is characterized by marked dropsy, and post 
mortem by the large white kidney. In the later stages of this process the 
kidney may be smaller — a condition known as the small white Icidney ; (b) 
chronic interstitial nephritis, in which dropsy is not common and the cardio- 
vascular changes are pronounced. Delafield recognizes a chronic diffuse 
nephritis with exudation and a chronic productive diffuse nephritis with- 
out exudation, the latter corresponding to the contracted kidney of authors. 

The amyloid kidney is usually spoken of as a variety of Bright's dis- 
ease, but in reality it is a degeneration which may accompany any form 
of nephritis. 



CHRONIC BRIGHT'S DISEASE. 



875 



Chronic Parenchymatous Nephritis 

(Chronic Desquamative and Chronic Tubal Nephritis ; Chronic Diffuse Nephritis with 

Exudation). 

Etiology. — In many cases the disease follows the acute nephritis of 
cold, scarlet fever, or pregnancy. More frequently than is usually stated 
the disease has an insidious onset and occurs independently of any acute 
attack. The fevers may play an important role in certain of these cases. 
Rosenstein, Bartels, and, in this country, I. E. Atkinson and Thayer have 
laid special stress upon malaria as a cause. Beer and alcohol are believed 
to lead to this form of nephritis. In chronic suppuration, syphilis, and 
tuberculosis the diffuse parenchymatous nephritis is not uncommon, and is 
usually associated with amyloid disease. Males are rather more subject to 
the affection than females. It is met with most commonly in young adults, 
and is by no means infrequent in children as a sequence of scarlatinal 
nephritis. 

Morbid Anatomy. — Several varieties of this form have been recog- 
nized. The most common is the large white kidney of Wilks, in which the 
organ is enlarged, the capsule is thin, and the surface white with the stellate 
veins injected. On section the cortex is swollen and yellowish white 
in color, and often presents opaque areas. The pyramids may be deeply 
congested. On microscopical examination it is seen that the epithelium 
is granular and fatty, and the tubules of the cortex are distended, and con- 
tain tube-casts. Hyaline changes are also present in the epithelial cells. 
The glomeruli are large, the capsules thickened, the capillaries show hyaline 
changes, and the epithelium of the tuft and of the capsule is extensively 
altered. The interstitial tissue is everywhere increased, though not to an 
extreme degree. 

The second variety of this form results from the gradual increase in 
the connective tissue and the subsequent shrinkage, forming what is called 
the small white kidney or the pale granular kidney. It is doubtful whether 
this is always preceded by the large white kidney. Some observers hold 
that it may be a primary independent form. The capsule is thickened and 
the surface is rough and granular. On section the resistance is greatly 
increased, the 'cortex is reduced and presents numerous opaque white or 
whitish-yellow foci, consisting of accumulations of fatty epithelium in the 
convoluted tubules. This combination of contracted kidney with the areas 
of marked fatty degeneration has given the name of small granular, fatty 
kidney to this form. The interstitial changes are marked, many of the 
glomeruli are destroyed, the degeneration of epithelium in the convoluted 
lubulos is widespread, and the arteries are greatly thickened. 

Belonging to this chronic tubal nephritis is a variety known as the 
chronic hemorrhagic nephritis, in which the organs are enlarged, yellowish 
white in color, and in the cortex are many brownish-red areas, due to haemor- 
rhage into and about the tubes. In other respects the changes are identical 
with those in the large white kidney. 

Of changes in the other organs the most marked are thickening of the 
blood-vessels and hypertrophy of the left heart. 



876 



DISEASES OF THE KIDNEYS. 



Symptoms. — Following an acute nephritis, the disease may present, 

in a modified way, the symptoms of that affection. In many cases it sets 
in insidionsly, and after an attack of dyspepsia or a period of failing health 
and loss of strength the patient becomes pale, and puffiness of the eyelids 
or swollen feet are noticed in the morning. 

The symptoms are as follows: The nrine is, as a rule, diminished in 
quantity, often scanty. It has a dirty-yellow, sometimes smoky, color, and 
is turbid from the presence of urates. On standing, a heavy sediment falls, 
in which are found numerous tube-casts of various forms and sizes, hyaline, 
both large and small, epithelial, granular, and fatty casts. Leucocytes are 
abundant; red blood-corpuscles are frequently met with, and epithelium 
from the kidneys and pelves. The albumin is abundant and may amount 
to one half or one third of the urine boiled. It is more abundant in the 
urine passed during the day. The specific gravity may be high in the early 
stages — from 1.020 to 1.025 — though in the later stages it is lower. The 
urea is always reduced in quantity. 

Dropsy is a marked and obstinate symptom of this form of Bright's 
disease. The face is pale and puffy, and in the morning the eyelids are 
oedematous. The anasarca is general, and there may be involvement of the 
serous sacs. In these chronic eases associated with large white kidney there 
is often a distinctive appearance in the face; the complexion is pasty, the 
pallor marked, and the eyelids are cedematous. The dropsy is peculiarly 
obstinate. Ursemic symptoms are common, though convulsions are perhaps 
less frequent than in the interstitial nephritis. 

The tension of the pulse is usually increased; the vessels ultimately 
become stiff and the heart hypertrophied, though there are instances of 
this form of nephritis in which the heart is not enlarged. The aortic second 
sound is accentuated. Eetinal changes though less frequent than in the 
chronic interstitial nephritis, occur in a considerable number of cases. 

Gastro-intestinal symptoms are common. Vomiting is frequently a 
distressing and serious symptom, and diarrhoea may be profuse. Ulcera- 
tion of the colon may occur and prove fatal. 

It is sometimes impossible to determine, even by the most careful ex- 
amination of the urine or by analysis of the symptoms, whether the con- 
dition of the kidney is that of the large white or of the small white form. 
In cases, however, which have lasted for several years, with the progressive 
increase in the renal connective tissue and the cardio-vascular changes, the 
clinical picture may approach, in certain respects, that of the contracted 
kidney. The urine is increased, with low specific gravity. It is often turbid, 
may contain traces of blood, the tube-casts are numerous and of every 
variety of form and size, and the albumin is abundant. Dropsy is usually 
present, though not so extensive as in the early stages. 

The prognosis is extremely grave. In a case which has persisted for 
more than a year recovery rarely takes place. Death is caused either by 
great effusion with oedema of the lungs, by uraemia, or by secondary inflam- 
mation of the serous membranes. Occasionally in children, even when the 
disease has persisted for two years, the symptoms disappear and recovery 
takes place. 



CHRONIC BRIGHT'S DISEASE. 



877 



Treatment. — Essentially the same treatment should be carried out as 
in acute Bright's disease. Milk or butter-milk should constitute the chief 
article of food. The dropsy should be treated by hydrotherapy. Iron prep- 
arations should be given when there is marked anaemia. It is to be remem- 
bered that the pallor of the face may not be a good index of the blood con- 
dition. Tyson thinks that the profession has been much too free in the 
use of iron in these cases. The acetate of potash, digitalis, and diuretin 
are useful in increasing the flow of urine. Basham's mixture given in plenty 
of water will be found beneficial. 

Chronic Interstitial Nephritis 

{Contracted Kidney; Granular Kidney; Cirrhosis of the Kidney; Gouty Kidney; 

Renal Sclerosis). 

Sclerosis of the kidney is met with (a) as a sequence of the large white 
kidney, forming the so-called pale granular or secondary contracted kidney; 
(b) as an independent primary affection; (c) as a sequence of arterio- 
sclerosis. 

Etiology. — The primary form is chronic from the outset, and is a 
slow, creeping degeneration of the kidney substance — in many respects 
only an anticipation of the gradual changes which take place in the organ 
in extreme old age. In many cases no satisfactory cause can be assigned. 
In others there are hereditary influences, as in the remarkable family studied 
by Dickinson, in which a pronounced tendency to chronic Bright's disease 
occurred in four generations. Families in which the arteries tend to de- 
generate early are more prone to interstitial nephritis. Syphilis is held 
by some to be a cause. Alcohol probably plays an important part, par- 
ticularly in conjunction with other factors. Among the better classes in 
this country chronic Bright's disease is very common, and is, I believe, 
caused more frequently by overeating than by excesses in alcohol. Some be- 
lieve excessive use of meat is injurious, since it increases the materials out 
of which uric acid is formed. By many a functional disorder of the liver, 
leading to lithaemia, is regarded as the most efficient factor. It is quite 
possible that in persons who habitually eat and drink too much the work 
thrown upon this organ is excessive, and the elaboration of certain mate- 
rials is so defective that in their excretion from the general circulation they 
irritate the kidneys. Actual gout, which in England is a common cause 
of interstitial nephritis, is not an important factor here. Lead, as is well 
known, may produce renal sclerosis. For a full discussion on the etiology 
and varieties of renal cirrhosis the student is referred to the recent work 
of S. West. 

Arteriosclerotic Form. — By far the most common form in this country 
is secondary to artcrio-sclerosis. The kidneys are not much, if at all, con- 
tracted, very hard, red, and show patches of cortical atrophy. It is seen 
in men over forty who have worked hard, eaten freely, and taken alcohol 
to excess. They are conspicuous victims of the " strenuous life," the inces- 
sant tension of which is felt first in the arteries. After forty in men of 
this class nothing is more salutary than to experience the shock brought by 



878 



DISEASES OF THE KIDNEYS. 



the knowledge of the presence of albumin and tube casts in the urine. 
The associated cardio-vaseular changes are of varying degrees of intensity, 
and upon them, not upon the renal condition, does the outlook depend. 

Morbid Anatomy. — The contracted kidneys are small, and together 
may weigh no more than an ounce and a half. The capsule is thick and 
adherent; the surface of the organ irregular and covered with small nodules, 
which have given to it the name of granular kidney. In stripping off the 
capsule, portions of the kidney substance are removed. Small cysts are 
frequently seen on the surface. The color is usually reddish, often a very 
dark red. On section the substance is tough and resists cutting; the cortex 
is thin and may measure no more than a couple of millimetres. The pyra- 
mids are less wasted. The small arteries are greatly thickened and stand 
out prominently. The fat about the pelvis is greatly increased. 

Microscopically there is seen a marked increase in the connective tissue 
and degeneration and atrophy of the secreting structures, glomerular and 
tubal, the former predominating and giving the main characters to the 
lesion. The following are the most important changes: 

(a) An increase in the fibrous elements, widely distributed throughout 
the organ, but more advanced in the cortex, particularly in the tissue be- 
tween the medullary rays. In the pyramids the distribution of new growth 
is less patchy and more diffuse. In the early stages of the process there 
is a small-celled infiltration between the tubes and around the glomeruli, 
and finally this becomes flbrillated and is seen encircling the tubules and 
Bowman's capsules, around the latter often forming concentric layers. 

(b) The changes in the glomeruli are striking, and in advanced cases 
a very considerable number of them have undergone complete atrophy and 
are represented as densely encapsulated hyaline structures. The atrophy 
is partly due to changes in the capillary walls and multiplication of cells 
between the loops, partly to extensive hyaline degeneration, and in part, 
no doubt, to the alterations in the afferent vessels. The normal glomeruli 
usually show some thickening of the capsule and increase in the cells of the 
tufts. 

(c) The tubules show changes in the epithelium, which vary a good 
deal in different localities. Where the connective-tissue growth is most 
advanced they are greatly atrophied and the epithelium may be repre- 
sented by small cubical cells. In other instances the epithelium has entirely 
disappeared. On the other hand, in the regions represented by the projecting 
granules the tubules are usually dilated, and the epithelium shows hyaline, 
fatty, and granular changes. Very many of them contain dark masses of 
epithelial debris and tube-casts. In the interstitial tissue and in the tubules 
there may be pigmentary changes due to haemorrhage. The dilatation of 
the tubules may reach an extreme grade, forming definite cysts. 

(d) The arteries show an advanced sclerosis. The intima is greatly 
thickened and there are changes in the adventitia and in the media, con- 
sisting in increase in the thickness due to proliferation of the connective 
tissue, in the latter coat at the expense of the muscular elements. 

The view most generally entertained at present is that the essential 
lesion is in the secreting tissues of the tubules and the glomeruli, and that 



CHRONIC BRIGHTS DISEASE. 



879 



the connective-tissue overgrowth is secondary to this. Greenfield holds that 
the primary change is in most instances in the glomeruli, to which both the 
degeneration in the epithelium of the convoluted tubules and the increase 
in the intertubular connective tissue are secondary. 

Associated with contracted kidney are general arterio-sclerosis and hyper- 
trophy of the heart. The changes in the arteries have already been de- 
scribed in the section on arterio-sclerosis. The hypertrophy of the heart is 
constant, and the enlargement may reach an extreme grade. Variations 
depend, no doubt, in part upon the extent of the diffuse arterial degenera- 
tion, but there are instances in which the term cor bovinum may be applied 
to the enlarged organ. In such cases the hypertrophy is not confined to 
the left ventricle, but involves the entire heart. The explanation of this 
hypertrophy has been much discussed. It was at first held to be due to 
the increased work thrown upon the organ in driving the impure blood 
through the capillary system. Basing his opinion upon the supposed mus- 
cular increase in the smaller arteries, Johnson regarded the hypertrophy as 
an effort to overcome a sort of stop-cock action of these vessels, which, under 
the influence of the irritating ingredient in the blood, contracted and in- 
creased greatly the peripheral resistance. Traube believed that the oblitera- 
tion of a large number of capillary territories in the kidney materially raised 
the arterial pressure, and in this way led to the hypertrophy of the heart; 
an additional factor, he thought, was the diminished excretion of water, 
which also heightened the pressure within the blood-vessels. 

With our present knowledge the most satisfactory explanation is that 
given by Cohnheim, which is thus clearly and succinctly put by Fagge: 
" He gives reasons for thinking that the activity of the circulation through 
the kidneys at any moment — in other words, the state of the smaller renal 
arteries as regards contraction or dilatation — depends not (as in the case 
of the tissues generally) upon the need of those organs for blood, but 
solely upon the amount of material for the urinary secretion that the cir- 
culatory fluid happens then to contain. This suggestion has bearings . . . 
upon the development of hypertrophy in one kidney when the other has 
been entirely destroyed. But another consequence deducible from it is 
that when parts of both kidneys have undergone atrophy, the blood-flow 
to the parts that remain must, cceteris paribus, be as great as it would have 
been to the whole of the organs if they had been intact. But in order that 
such a quantity of bloSd should pass through the restricted capillary area 
now open to it, an excessive pressure must obviously be necessary. This 
can be brought to bear only by the exertion of more than the normal degree 
of force on the part of the left ventricle, combined with the maintenance 
of a corresponding resistance in all other districts of the arterial system. 
And so one can account at once for the high arterial pressure and for the 
cardio-vascular changes that are secondary to it." 

Symptoms. — Perhaps a majority of the cases are latent, and are not 
recognized until the occurrence of one of the serious or fatal complications. 
Even an advanced grade of contracted kidney may be compatible with great 
mental and bodily activity. There may have been no svmptoms whatever 
to suggest to the patient the existence of a serious malady. In other cases 



880 



DISEASES OF THE KIDNEYS. 



the general health is disturbed. The patient complains of lassitude, is 
sleepless, has to get up at night to micturate; the digestion is disordered, 
the tongue is furred; there are complaints of headache, failing vision, and 
breathlessness on exertion. 

So complex and varied is the clinical picture of chronic Bright' s disease 
that it will be best to consider the symptoms under the various systems. 

Urinary System. — In the small contracted 'kidney polyuria is the rule. 
Frequently the patient has to get up two or three times during the night 
to empty the bladder, and there is increased thirst. It is for these symp- 
toms occasionally that relief is sought. The color is a light yellow, and the 
specific gravity ranges from 1.005 to 1.012. Persistent low specific gravity 
is one of the most constant and important features of the disease. Traces 
of albumin are found, but may be absent at times, particularly in the early 
morning urine. It is often simply a slight cloudiness, and may be apparent 
only with the more delicate tests. The sediment is scanty, and in it a few 
hyaline or granular casts are found. The quantity of the solid constituents 
of the urine is, as a rule, diminished, though in some instances the urea 
may be excreted in full amount. In attacks of dyspepsia or bronchitis, or 
in the later stages when the heart fails, the quantity of albumin may be 
greatly increased and the urine diminished. Occasionally blood occurs 
in the urine, and there may even be hematuria (S. West). Slight leakage, 
represented by the constant presence of a few red cells, may be present 
early in the disease and persist for years. In the arteriosclerotic form the 
quantity of urine is normal, or reduced rather than increased; the specific 
gravity is normal or high, the color of the urine is good, and there are 
hyaline and finely granular casts. The amount of albumin varies greatly 
with the food and exercise, and is usually much in excess of that seen with 
the contracted kidneys. 

Circulatory System. — The pulse is hard, the tension increased, and the 
vessel wall, as a rule, thickened. As already mentioned, a distinction must 
be made between increased tension and thickening of the arterial wall. The 
tension may be plus in a normal vessel, but in chronic Bright' s disease it is 
more common to have increased tension in a stiff artery. 

A pulse of increased tension has the following characters: It is hard 
and incompressible, requiring a good deal of force to overcome it; it is per- 
sistent, and in the intervals between the beats the vessel feels full and can 
be rolled beneath the finger. These characters may be present in a vessel 
the walls of which are little, if at all, increased in thickness. To estimate 
the latter the pulse wave should be obliterated in the radial, and the vessel 
wall felt beyond it. In a perfectly normal vessel the arterial coats, under 
these circumstances, cannot be differentiated from the surrounding tissue; 
whereas, if thickened, the vessel can be rolled beneath the finger. Per- 
sistent high tension is one of the earliest and most important symptoms of 
interstitial nephritis. The cardiac features are equally important, though 
often less, obvious. Hypertrophy of the left ventricle occurs to overcome 
the resistance offered in the arteries. The enlargement of the heart ulti- 
mately becomes more general. The apex is displaced downward and to the 
left; the impulse is forcible and may be heaving. In elderly persons with 



CHRONIC BRIGHT'S DISEASE. 



881 



emphysema, the displacement of the apex may not be evident. The first 
sound at the apex may be duplicated; more commonly the second sound 
at the aortic cartilage is accentuated, a very characteristic sign of increased 
tension. The sound in extreme cases may have a bell-like quality. In many 
cases a systolic murmur develops at the apex, probably as a result of relative 
insufficiency. It may be loud and transmitted to the axilla. Finally the 
hypertrophy fails, the heart becomes dilated, gallop rhythm is present, and 
the general condition is that of a chronic heart-lesion. 

Respiratory System. — Sudden oedema of the glottis may occur. Effu- 
sion into the pleurae or sudden oedema of the lungs may prove fatal. Acute 
pleurisy and pneumonia are not uncommon. Bronchitis is a frequent ac- 
companiment, particularly in the winter. Sudden attacks of oppressed 
breathing, particularly at night, are not infrequent. This is often a uraemic 
symptom, but is sometimes cardiac. The patient may sit up in bed and 
gasp for breath, as in true asthma. Cheyne-Stokes breathing may be pres- 
ent, most commonly toward the close, but the patient may be walking about 
and even attending to his occupation. 

Digestive System. — Dyspepsia and loss of appetite are common. Severe 
and uncontrollable vomiting may be the first symptom. This is usually 
regarded as a manifestation of uraemia, but it may be present without any 
other indications, and I have known it to prove fatal without any suspicion 
that chronic Bright' s disease was present. Severe and even fatal diar- 
rhoea may develop. The tongue may be coated and the breath heavy and 
urinous. 

Nervous System. — Various cerebral manifestations have already been 
mentioned under uraemia. Headache, sometimes of the migraine type, may 
be an early and persistent feature of chronic Bright's disease. Cerebral 
apoplexy is closely related to interstitial nephritis. The haemorrhage may 
take place into the meninges or the cerebrum. It is usually associated with 
marked changes in the vessels. Neuralgias, in various regions, are not un- 
common. 

Special Senses. — Troubles in vision may be the first symptom of the 
disease. It is remarkable in how many cases of interstitial nephritis the 
condition is diagnosed first by trie ophthalmic surgeon. The flame-shaped 
retinal haemorrhages are the most common. Less frequent is diffuse retinitis 
or papillitis. Sudden blindness may supervene without retinal changes — 
uraemic amaurosis. Diplopia is a rare event. Recurring conjunctival and 
palpebral haemorrhages are fairly common. Auditory troubles are by no 
means infrequent in chronic Bright's disease. Ringing in the ears, with 
dizziness, is not uncommon. Various forms of deafness may occur. 

Shin. — CEdema is not common in interstitial nephritis. Slight puffiness 
of the ankles may be present, but in a majority of the cases dropsy does 
not supervene. When extensive, it is almost always the result of gradual 
failure of the hypertrophied heart. The skin is often dry and pale, and 
sweats are not common. In some instances the sweat may deposit a white 
frost of urea on the surface of the skin. Eczema is a common accompani- 
ment of chronic interstitial nephritis. Tingling of the fingers or numb- 
ness and pallor — the dead fingers — are not, as some suppose, in any way 



882 



DISEASES OF THE KIDNEYS. 



peculiar to Bright' s disease. Intolerable itching of the skin may be pres- 
ent, and cramps in the muscles are by no means rare. 

Haemorrhages are not infrequent; epistaxis may prove serious and ex- 
tensive; purpura may occur. Broncho-pulmonary haemorrhages are said, 
by some French writers, to be common, but no instance of it has come 
under my observation. Ascites is rare except in association with cirrhosis 
of the liver. 

Diagnosis. — The autopsy often discloses the true nature of the dis- 
ease, one of the many intercurrent affections of which may have proved 
fatal. The early stages of interstitial nephritis are not recognizable. In 
a patient with increased pulse tension (particularly if the vessel wall is 
sclerotic), with the apex beat of the heart dislocated to the left, the second 
aortic sound ringing and accentuated, the urine abundant and of low spe- 
cific gravity, with a trace of albumin and an occasional hyaline or granular 
cast, the diagnosis of interstitial nephritis may be safely made. Of all the 
indications, that offered by the pulse is the most important. Persistent 
high tension with thickening of the arterial wall in a man under fifty means 
that serious mischief has already taken place, that cardio-vascular changes 
are certainty, and renal most probably, present. It is important in the diag- 
nosis of this condition not to rest content with a single examination of the 
urine. Both the evening and the morning secretion should be studied. 
The sediment should be collected in a conical glass, and in looking for 
tube-casts a large surface should be examined with a tolerably low power 
and little light. The arterio-selerotic kidney may exist for a long time 
without the occurrence of albumin, or the albumin may be in very small 
quantities. Toward the end it is impossible to differentiate the primary 
interstitial nephritis from an arterio-selerotic kidney, nor clinically is it of 
any special value so to do. In middle-aged men, with very high tension, 
great thickening of the superficial arteries, and marked hypertrophy of the 
heart, the renal are more likely to be secondary to the arterial changes. 

Prognosis. — Chronic Bright's disease is an incurable affection, and 
the anatomical conditions on which it depends are quite as much beyond 
the reach of medicines as wrinkled skin or gray hair. Interstitial nephritis, 
however, is compatible with the enjoyment of life for many years, and it is 
now universally recognized that increased tension, thickening of the arterial 
walls, and polyuria with a small quantity of albumin, neither doom a man 
to death within a short time nor necessarily interfere with the pursuits of 
an active life so long as proper care be taken. I know patients who have 
had high tension and a little albumin in the urine with hyaline casts for 
ten, twelve, and, in one instance, fifteen years. Serious indications are the 
development of uraemic symptoms, dilatation of the heart, the onset of 
serous effusions, the development of Che} r ne-Stokes breathing, persistent 
vomiting, and diarrhoea. 

Treatment. — Patients without local indications or in whom the con- 
dition has been accidentally discovered should so regulate their lives as to 
throw the least possible strain upon heart, arteries, and kidneys. A quiet 
life without mental worry, with gentle but not excessive exercise, and resi- 
dence in an equable climate, should be recommended. In addition they 



CHRONIC BRIGHT'S DISEASE. 



883 



should be told to keep the bowels regular, the skiu active by a daily tepid 
bath with friction, and the urinary secretion free by drinking daily a defi- 
nite amount of either distilled water or some pleasant mineral water. Alco- 
hol should be strictly prohibited. Tea and coffee are allowable. 

The diet should be light and nourishing, and the patient should be 
warned not to eat excessively, and not to take meat more than once a day. 
Care in food and drink is probably the most important element in the treat- 
ment of these early cases. 

A patient in good circumstances may be urged to go away during the 
winter months, or, if necessary, to move altogether to a warm equable cli- 
mate, like that of Southern California. There is no doubt of the value in 
these cases of removal from the changeable, irregular weather which pre- 
vails in the temperate regions from November until April. 

At this period medicines are not required unless for certain special 
symptoms. Patients derive much benefit from an annual visit to certain 
mineral springs, such as Poland, Bedford, Saratoga, in this country, and 
Vichy and others in Europe. Mineral waters have no curative influence 
upon chronic Bright' s disease; they simply help the interstitial circulation 
and keep the drains flushed. In this early stage, when the patient's con- 
dition is good, the tension not high, and the quantity of albumin small, 
medicines are not indicated, since no remedies are known to have the slight- 
est influence upon the progress of the disease. Sooner or later symptoms 
arise which demand treatment. Of these the following are the most im- 
portant: 

(a) Greatly Increased Arterial Tension. — It is to be remembered that ' 
a certain increase of tension is not only necessary but unavoidable in chronic 
Bright's disease, and probably the most serious danger is too great lowering 
of the blood tension. The happy medium must be sought between such 
heightened tension as throws a serious strain upon the heart and risks rup- 
ture of the vessels and the low tension which, under these circumstances, 
is specially liable to be associated with serous effusions. In cases with per- 
sistent high tension the diet should be light, an occasional saline purge 
should be given, and sweating promoted by means of hot air or the hot 
bath. If these measures do not suffice, nitroglycerin may be tried, begin- 
ning with 1 minim of the 1-per-cent solution three times a day, and grad- 
ually increasing the dose if necessary. Patients vary so much in suscepti- 
bility to this drug that in each case it must be tested, the limit of dosage 
being that at which the patient experiences the physiological effect. As 
much as 10 minims of the 1-per-cent solution may be given three times a 
day. In many case I have given it in much larger doses for weeks at a 
time. I have never seen any ill effects from it. If the dose is excessive the 
patients complain at once of flushing or headache. Its use may be kept up 
for six or seven weeks, then stopped for a week and resumed. Its value 
is seen not only in the reduction of the tension, but also in the striking 
manner in which it relieves the headache, dizziness, and dyspnoea. 

(b) More or less ancemia is present in advanced cases, and is best met 
by the use of iron. Weir Mitchell, who has had a unique experience in 
certain forms of chronic Bright's disease, gives the tincture of the per- 



884 



DISEASES OF THE KIDNEYS. 



chloride of iron in large doses — from half a drachm to a drachm three times 
a day. He thinks that it not only benefits the anaemia, but that it also is 
an important means of reducing the arterial tension. 

(c) Many patients with Bright's disease present themselves for treat- 
ment with signs of cardiac dilatation; there is a gallop rhythm or the heart 
sounds have a foetal character, the breath is short, the urine scanty and 
highly albuminous, and there are signs of local dropsy. In these cases the 
treatment must be directed to the heart. A morning dose of salts or calo- 
mel may be given, and digitalis in 10-minim doses, three or four times a 
day. Strychnia may be used with benefit in this condition. In some in- 
stances other cardiac tonics may be necessary, but as a rule the digitalis acts 
promptly and well. 

(d) Urcemic Symptoms. — Even before marked manifestations are present 
there may be extreme restlessness, mental wandering, a heavy, foul breath, 
and a coated tongue. Headache is not often complained of, though intense 
frontal headache may be an early symptom of uraemia. In this condition, 
too, the patient may complain of palpitation, feelings of numbness, and 
sometimes nocturnal cramps. For these symptoms the saline purgatives 
should be ordered, and hot baths, so as to induce copious sweating. Grandin 
states that irrigation of the bowel with water at a temperature from 120° 
to 150° is most useful. Nitroglycerin also may be freely used to reduce the 
tension. For the uraemic convulsions, if severe, inhalations of chloroform 
may be used. If the patient is robust and full-blooded, from 12 to 20 ounces 
of blood should be removed. The patient should be freely sweated, and if 
the convulsions tend to recur chloral may be given, either by the mouth or 
per rectum, or, better still, morphia. Uraemic coma must be treated by 
active purgation, and sweating should be promoted by the use of pilocar- 
pine or the hot bath. For the restlessness and delirium morphia is indis- 
pensable. Since its recommendation in uraemic states some years ago, by 
Stephen MacKenzie, I have used this remedy extensively and can speak of 
its great value in these eases. I have never seen ill effects or any tendency 
to coma follow. It is of special value in the dyspnoea and Cheyne-Stokes 
breathing of advanced arterio-sclerosis with chronic uraemia. 



VIII. AMYLOID DISEASE. 

Amyloid (lardaceous or waxy) degeneration of the kidneys is simply an 
event in the process of chronic Bright's disease, most commonly in the 
chronic parenchymatous nephritis following fevers, or of cachectic states. 
It has no claim to be regarded as one of the varieties of Bright's disease. 
The affection of the kidneys is generally a part of a widespread amyloid 
degeneration occurring in prolonged suppuration, as in disease of the bone, 
in syphilis, tuberculosis, and occasionally leukaemia, lead poisoning, and 
gout. It varies curiously in frequency in different localities. 

Anatomically the amyloid kidney is large and pale, the surface smooth, 
and the venae stellatae well marked. On section the cortex is large and 
may show a peculiar glistening, infiltrated appearance, and the glomeruli 



AMYLOID DISEASE. 



885 



are very distinct. The pyramids, in striking contrast to the cortex, are of 
a deep red color. A section soaked in dilute tincture of iodine shows spots 
of a walnut or mahogany brown color. The Malpighian tufts and the 
straight vessels may be most affected. In lardaceous disease of the kidneys 
the organs are not always enlarged. They may be normal in size or small, 
pale, and granular. The amyloid change is first seen in the Malpighian 
tufts, and then involves the afferent and efferent vessels and the straight 
vessels. It may be confined entirely to them. In later stages of the dis- 
ease the tubules are affected, chiefly the membrane, rarely, if ever, the cells 
themselves. In addition, the kidneys always show signs of diffuse nephritis. 
The Bowman's capsules are thickened, there may be glomerulitis, and the 
tubal epithelium is swollen, granular, and fatty. 

Symptoms. — The renal features alone may not indicate the presence 
of this degeneration. Usually the associated condition gives a hint of the 
nature of the process. The urine, as a rule, shows important changes; 
the quantity is increased, and it is pale, clear, and of low specific gravity. 
The albumin is usually abundant, but it may be scanty, and in rare in- 
stances absent. Possibly the variations in the situation of the amyloid 
changes may account for this, since albumin is less likely to be present 
when the change is confined to the vasa recta. In addition to ordinary 
albumin globulin may be present. The tube-casts are variable, usually 
hyaline, often fatty or finely granular. Occasionally the amyloid reaction 
can be detected in the hyaline casts. Dropsy is present in many instances, 
particularly when there is much anaemia or profound cachexia. It is not, 
however, an invariable symptom, and there are cases in which it does not 
develop. Diarrhoea is a common accompaniment. 

Increased arterial tension and cardiac hypertrophy are not usually pres- 
ent, except in those cases in which amyloid degeneration occurs in the 
secondary contracted kidney; under which circumstances there may be 
uraemia and retinal changes, which, as a rule, are not met with in other 
forms. 

Diagnosis.' — By the condition of the urine alone it is not possible to 
recognize amyloid changes in the kidney. Usually, however, there is no 
difficulty, since the Bright' s disease comes on in association with syphilis, 
prolonged suppuration, disease of the bone, or tuberculosis, and there is 
evidence of enlargement of the liver and spleen. A suspicious circum- 
stance is the existence of polyuria with a large amount of albumin in the 
urine, or when, in these constitutional affections, a large quantity of clear, 
pale urine is passed, even without the presence of albumin. 

The prognosis depends rather on the condition with which the nephritis 
is associated. As a rule it is grave. 

The treatment of the condition is that of chronic Bright's disease. 



886 



DISEASES OF THE KIDNEYS. 



IX. PYELITIS. 

{Consecutive Nephritis ; Pyelonephritis ; Pyonephrosis) 

Definition. — Inflammation of the pelvis of the kidney and the con- 
ditions which result from it. 

Etiology. — Pyelitis in almost all cases is induced by bacterial invasion 
and multiplication, rarely by the irritation of various substances such as 
turpentine, cubebs, or sugar (diabetes). Normally the kidney can eliminate 
without harm to itself, apparently, various bacteria carried to it by the 
blood-current from the intestinal tract or some focus of infection; and it 
probably becomes infected only where its resistance is lowered, as a result 
of some general cause, as anaemia, malnutrition, or intercurrent disease, 
or of some local cause, as nephritis, displacement, congestion due to pres- 
sure of neoplasms upon the ureter, twisted ureter (DietPs crisis), or of 
operation, or where the number or virulence of the micro-organisms is in- 
creased. These same factors probably play an important role also in the 
other common causes of pyelitis, ascending infection from an infected blad- 
der (cystitis), and tuberculous infection. Other causes described are vari- 
ous fevers, cancer, hydatids, the ova of certain parasites, cold, and over- 
exertion. Calculus seems not to be a common cause, as, if present at all, 
it is probably consecutive to the infection. In T. R. Brown's series of 20 
cases, the colon bacillus was obtained 7 times, the tubercle bacillus 6, the 
proteus bacillus 4, a white staphylococcus twice — all in pure culture — while 
in 1 case cultures were negative. 

Morbid Anatomy. — In the early stages of pyelitis the mucous mem- 
brane is turbid, somewhat swollen, and may show ecchymoses or a grayish 
pseudo-membrane. The urine in the pelvis is cloudy, and, on examina- 
tion, numbers of epithelial cells are seen. 

In the calculous pyelitis there may be only slight turbidity of the mem- 
brane, which has been called by some catarrhal pyelitis. More commonly 
the mucosa is roughened, grayish in color, and thick. Under these circum- 
stances there is almost always more or less dilatation of the calyces and 
flattening of the papillae. Following this condition there may be (a) ex- 
tension of the suppurative process to the kidney itself, forming a pyelo- 
nephritis; (b) a gradual dilatation of the calyces with atrophy of the kidney 
substance, and finally the production of the condition of pyonephrosis, in 
which the entire organ is represented by a sac of pus with or without a 
thin shell of renal tissue, (c) After the kidney structure has been destroyed 
by suppuration, if the obstruction at the orifice of the pelvis persists, the 
fluid portions may be absorbed and the pus become inspissated, so that the 
organ is represented by a series of sacculi containing grayish, putty-like 
masses, which may become impregnated with lime salts. 

Tuberculous pyelitis, as already described, usually starts upon the apices 
of the pyramids, and may at first be limited in extent. Ultimately the 
condition produced may be similar to that of calculous pyelitis. Pyone- 
phrosis is quite as frequent a sequence, while the final transformation of 



PYELITIS. 



887 



the pus into a putty-like material impregnated with salts, forming the 
so-called scrofulous kidney, is even commoner. 

The pyelitis consecutive to cystitis is generally unilateral, and the kidney 
is sometimes involved, forming the so-called surgical kidney — acute sup- 
purative nephritis. There are lines of suppuration extending along the 
pyramids, or small abscesses in the cortex, often just beneath the capsule; 
or there may be wedge-shaped abscesses. The pus organisms either pass 
up the tubules or, as Steven has shown, through the lymphatics. 

Symptoms. — The forms associated with the fevers rarely cause any 
symptoms, even when the process is extensive. In mild grades there is 
pain in the back or there may be tenderness on deep pressure on the af- 
fected side. The urine, turbid and containing pus cells, some mucus, and 
occasional red blood-cells, is acid or alkaline, depending on the infecting 
microbe; usually the albuminuria is of higher grade comparatively than 
the pyuria. 

Before the condition of pyuria is established there may be attacks of 
pain on the affected side (not amounting to the severe agony of renal colic), 
rigors, high fever, and sweats. Under these circumstances the urine, which 
may have been clear, becomes turbid or smoky from the presence of blood, 
and may contain large numbers of mucus cells and transitional epithelium. 
These cases are not common, but I have twice had opportunity of studying 
such attacks for a prolonged period. In one patient the occurrence of the 
rigor and fever could sometimes be predicted from the change in the con- 
dition of the urine. Such cases occur, I believe, in association with calculi 
in the pelvis. 

The statement is not infrequently made that the epithelium in the 
urine in pyelitis is distinctive and characteristic. This is erroneous, as 
may be readily demonstrated by comparing scrapings of the mucosa of the 
renal pelvis and of the bladder. In both the epithelium belongs to what is 
called the transitional variety, and in both regions the same conical, fusi- 
form and irregular cells with long tails are found. 

When the pyelitis, whether calculous or tuberculous, has become chronic 
and discharges, the symptoms are: 

(1) Pyuria. — The pus is in variable amount, and may be intermittent. 
Thus, as is often the case when only one kidney is involved, the ureter 
may be temporarily blocked, and normal urine is passed for a time; then 
there is a sudden outflow of the pent-up pus and the urine becomes puru- 
lent. Coincident with this retention, a tumor mass may be felt on the 
side affected. The pus has the ordinary characters, but the transitional 
epithelium is not so abundant at this stage and comes from the bladder or 
from the pelvis of the healthy side. Occasionally in rapidly advancing 
pyelonephritis, portions of the kidney tissue, particularly of the apices of 
the pyramids, may slough away and appear in the urine; or, as in a re- 
markable specimen shown to me by Tyson, solid cheesy moulds of the 
calyces are passed. Casts from the kidney tubules are sometimes present. 
The reaction of the urine depends entirely upon the infecting microbe, 
whether the condition is unilateral or bilateral, and whether the bladder 
is also infected, when vesical irritability and frequent micturition may be 
present. Polyuria is usually present in the chronic cases. 



888 



DISEASES OF THE KIDNEYS. 



(2) Intermittent fever associated with rigors is usually present in cases 
of suppurative pyelitis. The chills may recur at regular intervals, and 
the cases are often mistaken for malaria. Owen-Kees called attention to 
the frequent occurrence of these rigors, which form a characteristic feature 
of hoth calculous and tuberculous pyelitis. Ultimately the fever assumes 
a hectic type and the rigors may cease. 

(3) The general condition of the patient often indicates prolonged 
suppuration. There is more or less wasting with anaemia and a progressive 
failure of health. Secondary abscesses may develop and the clinical picture 
becomes that of pyaamia. In some instances, particularly of tuberculous 
pyelitis, the clinical course may resemble that of typhoid fever. There are 
instances of pyuria recurring, at intervals, for many years without impair- 
ment of the bodily vigor. Some of the chronic cases have practically no 
discomfort. 

(4) Physical examination in chronic pyelitis usually reveals tenderness 
on the affected side or a definite swelling, which may vary much in size 
and ultimately attain large dimensions if the kidney becomes enormously 
distended, as in pyonephrosis. 

(5) Occasionally nervous sjmrptoms, which may be associated with 
dyspnoea, supervene, or the termination may be by coma, not unlike that 
of diabetes. These have been attributed to the absorption of the decom- 
posing materials in the urine, whence the so-called ammoniaemia. A form 
of paraplegia has been described in connection with some cases of abscess 
of the kidney, but whether due to a myelitis or to a peripheral neuritis has 
not yet been determined. 

In suppurative nephritis or surgical kidney following cystitis, the pa- 
tient complains of pain in the back, the fever becomes high, irregular, and 
associated with chills, and in acute cases a typhoid state develops in which 
death occurs. 

Diagnosis. — Between the tuberculous and the calculous forms of 
pyelitis it may be difficult or impossible to distinguish, except by the de- 
tection of tubercle bacilli in the pus. The examination for bacilli should 
be made systematically, and in suspicious cases intraperitoneal injections 
of guinea-pigs should also be made. From perinephric abscess pyonephrosis 
is distinguished by the more definite character of the tumor, the absence of 
oedematous swelling in the lumbar region, and, most important of all, the 
history of the case. The urine, too, in perinephric abscess may be free from 
pus. There are cases, however, in which it is difficult indeed to make a 
satisfactory diagnosis. A patient, whom I saw with Fussell, had had cystitis 
through her pregnancy, subsequently pus in the urine for several months, 
and then a large fluctuating abscess developed in the right lumbar region. 
It did not seem possible, either before or during the operation, to deter- 
mine whether the case was a simple pyonephrosis or whether there had been 
a perinephric abscess caused by the pyelitis. 

Suppurative pyelitis and cystitis are frequently confounded. I have 
known instances of the former in which perineal section was performed on 
the supposition of the existence of an intractable cystitis. The two condi- 
tions may, of course, coexist and prove puzzling, but the history, the higher 



HYDRONEPHROSIS. 



889 



relative grade of albuminuria in pyelitis (Rosenfeld, Goldberg, T. K. 
Brown), the polyuria, the mode of development, the local signs in one lum- 
bar region, and the absence of pain in the bladder, should be sufficient to 
differentiate the affections. In women, by catheterization of the ureters, 
it may be definitely determined whether the pus comes from the kidneys or 
from the bladder. The cystoscope may be used for this purpose. 

Prognosis. — Cases coming on during the fevers usually recover. Tu- 
berculous pyelitis may terminate favorably by inspissation of the pus and 
conversion into a putty-like substance with deposition of lime salts. When 
pyonephrosis develops the dangers are increased. Perforation may occur, 
the patient may be worn out by the hectic fever, or amyloid disease may 
develop. 

Treatment. — In mild cases fluids should be taken freely, particularly 
the alkaline mineral waters, to w^hich potassium citrate may be added. 

The treatment of the calculous form will be considered later. Practi- 
cally there are no remedies which have much influence upon the pyuria. 
Some of the recently described urinary antiseptics, as urotropin, etc., seem 
to be of value, especially in the acute cases. Tonics should be given, a 
nourishing diet, and milk and butter-milk may be taken freely. When the 
tumor has formed or even before it is perceptible, if the symptoms are 
serious and severe, the kidney should be explored, and, if necessary, ne- 
phrotomy or nephrectomy should be performed. 

X. HYDRONEPHROSIS. 

Definition. — Dilatation of the pelvis and calyces of the kidney with 
atrophy of its substance, caused by the accumulation of non-purulent fluids, 
the result of obstruction. 

Etiology. — The condition may be congenital, owing to some abnor- 
mality in the ureter or urethra. The tumor produced may be large enough 
to retard labor. Sometimes it is associated with other malformations. There 
is a condition of moderate dilatation, apparently congenital, which is not 
connected with any obstruction in the ducts. A case of the kind was shown 
at the Philadelphia Pathological Society by Daland. 

In some instances there has been contraction or twisting of the ureter, 
or it has been inserted into the kidney at an acute angle or at a high level. 
In adult life the condition may be due to lodgment of a calculus, or to a 
cicatricial stricture following ulcer. 

New growths, such as tubercle or cancer, occasionally induce hydro- 
nephrosis; more commonly, pressure upon the ureter from without, par- 
ticularly tumors of the ovaries and uterus. Occasionally cicatricial bands 
compress the ureter. Obstruction within the bladder may result from can- 
cer, from hypertrophy of the prostate with cystitis, and in the urethra from 
stricture. It is stated that slight grades of hydronephrosis have been found 
in patients with excessive polyuria. 

In whatever way produced, when the ureter is blocked the secretion ac- 
cumulates in the pelvis and infundibula. Sometimes acute inflammation 
follows, but more commonly the slow, gradual pressure causes atrophy of 
55 



890 



DISEASES OF THE KIDNEYS. 



the papillae with gradual distention and wasting of the organ. In acquired 
cases from pressure, even when dilatation is extreme, there may usually be 
seen a thin layer of renal structure. In the most extreme stages the kid- 
ney is represented by a large cyst, which may perhaps show on its inner 
surface imperfect septa. The fluid is thin and yellowish in color, and con- 
tains traces of urinary salts, urea, uric acid, and sometimes albumin. The 
secretion may be turbid from admixture with small quantities of pus. 

Total occlusion does not always lead to a hydronephrosis, but may be 
followed by atrophy of the kidney. It appears that when the obstruction 
is intermittent or not complete the greatest dilatation is apt to follow. The 
sac may be enormous, and cause an abdominal tumor of the largest size. 
The condition has even been mistaken for ascites. Enlargement of the 
other kidney may compensate for the defect. Hypertrophy of the left side 
of the heart usually follows. 

Symptoms. — When small, it may not be noticed. The congenital 
cases when bilateral usually prove fatal within a few days; when unilateral, 
the tumor may not be noticed for some time. It increases progressively 
and has all the characters of a tumor in the renal region. In adult life 
many of the cases, due to pressure by tumors, as in cancer of the uterus 
and enlargement of the prostate, etc., give rise to no symptoms. 

There are remarkable instances of intermittent hydronephrosis in which 
the tumor suddenly disappears with the discharge of a large quantity of 
clear fluid. The sac gradually refills, and the process may be repeated for 
years. In these cases the obstruction is unilateral; a cicatricial stricture 
exists, or a valve is present in the ureter, or the ureter enters the upper 
part of the pelvis. Many of the cases are in women and associated with 
movable kidney. 

The examination of the abdomen shows, in unilateral hydronephrosis, 
a tumor occupying the renal region. When of moderate size it is readily 
recognized, but when large it may be confounded with ovarian or other 
tumors. In young children it may be mistaken for sarcoma of the kidney 
-or of the retroperitoneal glands, the common cause of abdominal tumor 
in early life. Aspiration alone would enable us to differentiate between 
hydronephrosis and tumor. The large hydronephrotic sac is frequently 
mistaken for ovarian tumor. The latter is, as a rule, more mobile, and 
rarely fills the deeper portion of the lumbar region so thoroughly. The 
ascending colon can often be detected passing over the renal tumor, and 
examination per vaginam, particularly under ether, will give important 
indications as to the condition of the ovaries. In doubtful cases the sac 
should be aspirated. The fluid of the renal cyst is clear, or turbid from the 
presence of cell elements, rarely colloid in character; the specific gravity 
is low; albumin and traces of urea and uric acid are usually present; and 
the epithelial elements in it may be similar to those found in the pelvis of the 
kidney. In old sacs, however, the fluid may not be characteristic, since the 
urinary salts disappear, but in one case of several years' duration oxalates 
of lime and urea were found. 

Perhaps the greatest difficulty is offered by the condition of hydro- 
nephrosis in a movable kidney. Here, the history of sudden disappear- 



NEPHROLITHIASIS. 



891 



ance of the tumor with the passage of a large quantity of clear fluid would 
be a point of great importance in the diagnosis. In those rare instances 
of an enormous sac filling the entire abdomen, and sometimes mistaken 
for ascites, the character of the fluid might be the only point of difference, 
The tumor of pyonephrosis may be practically the same in physical char- 
acteristics. Fever is usually present, and pus is often found in the urine. 
In these cases, when in doubt, exploratpry puncture should be made. 

The outlook in hydronephrosis depends much upon the cause. When 
single, the condition may never produce serious trouble, and the intermit- 
tent cases may persist for years and finally disappear. Occasionally the cyst 
ruptures into the peritonaeum, more rarely through the diaphragm into the 
lung. A remarkable case of this kind was under the care of my colleague, 
Halsted. A man, aged twenty-one, had, from his second year, attacks of 
abdominal pain in which a swelling would appear between the hip and 
costal margin and subside with the passage of a large amount of urine. 
In January, 1888, the sac discharged through the right lung.* Keaccumu- 
lations occurred on several occasions, and on June 9, 1891, the sac was 
opened and drained. He remains well, though there is still a sinus through 
which a clear, probably urinous, fluid is discharged. 

The sac may discharge spontaneously through the ureter and the fluid 
never reaccumulate. In bilateral hydronephrosis there is a danger that 
uraemia may supervene. There are instances, too, in which blocking, of 
the ureter on the sound side by calculus has been followed by uraemia. 
And, lastly, the sac may suppurate, and the condition change to one of 
pyonephrosis. 

Treatment. — Cases of intermittent hydronephrosis which do not cause 
serious symptoms should be let alone. It is stated that, in sacs of moderate 
size, the obstruction has been overcome by shampooing. If practised, it 
should be done with great care. When the sac reaches a large size aspira- 
tion may be performed and repeated if necessary. Puncture should be 
made in the flank, midway between the ilium and the last rib. If the fluid 
reaccumulates and the sac becomes large, it may be incised and drained, or, 
as a last resort, the kidney may be removed. In women a carefully adapted 
pad and bandage will sometimes prevent the recurrence of an intermittent 
hydronephrosis, f 



XI. NEPHROLITHIASIS {Renal Calculus). 

Definition. — The formation in the kidney or in its pelvis of con- 
cretions, by the deposition of certain of the solid constituents of the urine. 

Etiology and Pathology.— In the kidney substance itself the sepa- 
ration of the urinary salts produces a condition to which, unfortunately, 
the term infarct has been applied. Three varieties may be recognized: (1) 
The uric-acid infarct, usually met with at the apices of the pyramids in 



* Sowers, New York Medical Record, 1888. 

f See illustrative cases in ray Lectures on Abdominal Tumors, 1894. 



892 



DISEASES OF THE KIDNEYS. 



new-born children and during the first weeks of life. The priapism and 
attacks of crying in the new-born have been attributed to the passage of 
these infarcts (Southworth); (2) the sodium-urate infarct, sometimes asso- 
ciated with ammonium urate, which forms whitish lines at the apices of 
the pyramids and is met with chiefly, but not always, in gouty persons; and 
(3) the lime infarcts, forming very opaque white lines in the pyramids, 
usually in old people. 

In the pelvis and calyces concretions of the following forms occur: (a) 
Small gritty particles, renal sand, ranging in size from the individual grains 
of the uric-acid sediment to bodies 1 or 2 mm. in diameter. These may be 
passed in the urine for long periods without producing any symptoms, since 
they are too fine to be arrested in their downward passage. 

(b) Larger concretions, ranging in size from a small pea to a bean, and 
either solitary or multiple in the calyces and pelvis. It is the smaller of 
these calculi which, in their passage, produce the attacks of renal colic. 
They may be rounded and smooth, or present numerous irregular projec- 
tions. 

(c) The dendritic form of calculus. The orifice of the ureter may be 
blocked by a Y-shaped stone. The pelvis itself may be occupied by the 
concretion, which forms a more or less distinct mould. These are the re- 
markable coral calculi, which form in the pelvis complete moulds of in- 
fundibula and calyces, the latter even presenting cup-like depressions cor- 
responding to the apices of the papillae. Some of these casts in stone of 
the renal pelvis are as beautifully moulded as HyrtPs corrosion prepara- 
tions. 

Chemically the varieties of calculi are: (1) Uric acid and urates, most 
important, and forming the renal sand, the small solitary, or the large 
dendritic stones. They are very hard, the surface is smooth, and the color 
reddish. The larger stones are usually stratified and very dense. Usually 
the uric acid and the urates are mixed, but in children stones composed of 
urates alone may occur. 

(2) Oxalate of lime, which forms mulberry-shaped calculi, studded with 
points and spines. They are often very dark in color, intensely hard, and 
are a mixture of oxalate of lime and uric acid. 

(3) Phosphatic calculi are composed of the calcium phosphate and the 
ammonio-magnesium phosphate, sometimes mixed with a small amount of 
calcium carbonate. They are quite common, although the phosphatic salts 
are often deposited about the uric acid or the calcium-oxalate stones. 

(4) Eare forms of calculi are made up of cystine, xanthine, carbonate of 
lime, indigo, and urostealith. 

The mode of formation of calculi has been much discussed. They may 
be produced by an excess of a sparingly soluble abnormal ingredient, such 
as cystine or xanthine; more frequently by the presence of uric acid in a 
very acid urine which favors its deposition. Sir William Eoberts thus 
briefly states the conditions which lead to the formation of the uric-acid 
concretions: high acidity, poverty in salines, low pigmentation, and high 
percentage of uric acid. Ord suggests that albumin, mucus, blood, and 
epithelial threads may be the starting-point of stone. The demonstration 



NEPHROLITHIASIS. 



893 



of organisms in the centre of renal calculi renders it probable that in many- 
cases the nucleus of the stone is an agglutinated mass of bacteria. 

Eenal calculi are most common in the early and later periods of life. 
They are moderately frequent in this country, but there do not appear to 
be special districts, corresponding to the " stone counties " in England. 
Men are more often affected than women. Sedentary occupations seem to 
predispose to stone. 

The effects of the calculi are varied. It is by no means uncommon to 
find a dozen or more stones of various sizes in the calyces without any 
destruction of the mucous membrane or dilatation of the pelvis. A tur- 
bid urine fills the pelvis in which there are numerous cells from the epi- 
thelial lining. There are cases of this sort in which, apparently, the stones 
may go on forming and are passed for years without seriously impairing 
the health and without inconvenience, except the attacks of renal colic. 
Still more remarkable are the cases of coral-like calculi, which may occupy 
the entire pelvis and calyces without causing pyelitis, but which gradually 
lead to more or less induration of the kidney. The most serious effects 
are when the stone excites a suppurative pyelitis and pyonephrosis. 

Symptoms. — Patients may pass gravel for years without having an 
attack of renal colic, and a stone may never lodge in the ureter. In other 
instances, the formation of calculi goes on year by year and the patient has 
recurring attacks such as have been so graphically described by Montaigne 
in his own case. A patient may pass an enormous number of calculi. 
Some years ago I was consulted by a commercial traveller, an extremely 
vigorous man, who for many years had had repeated attacks of renal colic, 
and had passed several hundred calculi of various sizes. His collection filled 
an ounce bottle. A patient may pass a single calculus, and never be trou- 
bled again. The large coral calculi may excite no symptoms. In a re- 
markable specimen of the kind, presented to the McGill Medical Museum 
by J. A. Macdonald, the patient, a middle-aged woman, died suddenly with 
uraemic symptoms. There was no pyelitis, but the kidneys were sclerotic. 

Renal colic ensues when a stone enters the ureter. An attack may set 
in abruptly without apparent cause, or may follow a strain in lifting. 
It is characterized by agonizing pain, which starts in the flank of the 
affected side, passes down the ureter, and is felt in the testicle and along 
the inner side of the thigh. The pain may also radiate through the ab- 
domen and chest, and be very intense in the back. In severe attacks there 
are nausea and vomiting and the patient is collapsed. The perspiration 
breaks out upon the face and the pulse is feeble and quick. A chill may 
precede the outbreak, and the temperature may rise as high as 103°. No 
one has more graphically described an attack of " the stone " than Mon- 
taigne,* who was a sufferer for many years: " Thou art seen to sweat with 
pain, to look pale and red, to tremble, to vomit Avell-nigh to blood, to sullVr 
strange contortions and convulsions, by starts to let tears drop from thine 
eyes, to urine thick, black, and frightful water, or to have it suppressed 
by some sharp and craggy stone, that cruelly pricks and tears thee." The 



* Essays, Book III, 13. 



894 



DISEASES OF THE KIDNEYS. 



symptoms persist for a variable period. In short attacks they do not last 
longer than an hour; in other instances they continue for a day or 
more, with temporary relief. Micturition is frequent, occasionally painful, 
and the urine, as a rule, is bloody. There are instances in which a large 
amount of clear urine is passed, probably from the other kidney. In rare 
cases the secretion of urine is completely suppressed, even when the kidney 
on the opposite side is normal, and death may occur from uraemia. This 
most frequently happens when the second kidney is extensively diseased, 
or when only a single kidney exists. A number of cases of this kind have 
been recorded. The condition has been termed, by Sir William Roberts, 
obstructive suppression. It is met with also when cancer compresses both 
ureters or involves their orifices in the bladder. The patient may not ap- 
pear to be seriously ill at first, and urasmic symptoms may not develop for 
a week, when twitching of the muscles, great restlessness, and sometimes 
drowsiness supervene, but, strange to say, neither convulsions nor coma. 
Death takes place usually within twelve days from the onset of the ob- 
struction. 

After the attack of colic has passed there is more or less aching on the 
affected side, and the patient can usually tell from which kidney the stone 
has come. Examination during the attack is usually negative. Very rarely 
the kidney becomes palpable. Tenderness on the affected side is common. 
In very thin persons it may be possible, on examination of the abdomen, 
to feel the stone in the ureter; or the patient may complain of a grating 
sensation. 

When the calculi remain in the kidney they may produce very definite 
and characteristic symptoms, of which the following are the most im- 
portant: 

(1) Pain, usually in the back, which is often no more than a dull sore- 
ness, but which may be severe and come on in paroxysms. It is usually on 
the side affected, but may be referred to the opposite kidney, and there are 
instances in which the pain has been confined to the sound side. Pains 
of a similar nature may occur in movable kidneys, and there arc several 
instances on record in which surgeons have incised the kidney for stone 
and found none. In an instance in which pain was present for a couple 
of years the exploration revealed only a contracted kidney. 

(2) Hwmaturia. — Although this occurs most frequently when the stone 
becomes engaged in the ureter, it may also come on when the stones are 
in the pelvis. The bleeding is seldom profuse, as in cancer, but in some 
instances may persist for a long time. It is aggravated by exertion and 
lessened by rest. Frequently it only gives to the urine a smoky hue. The 
urine may be free for days, and then a sudden exertion or a prolonged ride 
may cause smokiness, or blood may be passed in considerable quantities. 

(3) Pyelitis. — (a) There may be attacks of severe pain in the back, not 
amounting to actual colic, which are initiated by a heavy chill followed 
by fever, in which the temperature may reach 104° or 105°, followed by 
profuse sweating. The urine, which has been clear, may become turbid 
and smoky and contain blood and abundant epithelium from the pelvis. 
Attacks of this description may recur at intervals for months or even 



NEPHROLITHIASIS. 



895 



years, and are generally mistaken for malaria, unless special attention is 
paid to the urine and to the existence of the pain in the back. This renal 
intermittent fever, due to the presence of calculi, is analogous to the he- 
patic intermittent fever, due to gall-stones, and in both it is important to 
remember that the most intense paroxysms may occur without any evi- 
dence of suppuration. 

(b) More frequently the symptoms of purulent pyelitis, which have al- 
ready been described, are present; pain in the renal region, recurring chills, 
and pus in the urine, with or without indications of pyonephrosis. 

(4) Pyuria. — There are instances of stone in the kidney in which pus 
occurs continuously or intermittently in the urine for many years. On 
many occasions between 1875 and 1884 I examined the urine of a physician 
who had passed calculi when a student in 1845, and had pus in the urine 
at intervals to 1891. In spite of the prolonged suppuration he had remark- 
able mental and bodily vigor. 

Patients with stone in the kidney are often robust, high livers, and 
gouty. Attacks of dyspepsia are not uncommon, or they may have severe 
headaches. 

Diagnosis. — Renal may be mistaken for intestinal colic, particularly 
if the distention of the bowels is marked, or for biliary colic. The situa- 
tion and direction of the pain 7 the retraction and tenderness of the testicle, 
the occurrence of hematuria, and the altered character of the urine are 
distinctive features. Attention may again be called to the fact that at- 
tacks simulating renal colic are associated with movable kidney, or even, 
it has been supposed, without mobility of the kidney, with the accumu- 
lation of the oxalates or uric acid in the pelvis of the kidney. The diag- 
nosis between a stone in the kidney and stone in the bladder is not always 
easy, though in the latter the pain is particularly about the neck of the 
bladder, and not limited to one side. In the uric-acid or uratic renal stone, 
the urine is acid, thus aiding us in differentiating it from a bladder stone, 
when alkaline urine is the rule. It is stated that certain differences occur 
in the symptoms produced by different sorts of calculi. The large uric-acid 
calculi less frequently produce severe symptoms. On the other hand, as 
the oxalate of lime is a rougher calculus, it is apt to produce more pain 
(often of a radiating character) than the lithic-acid form, and to cause 
haemorrhage. In both these forms the urine is acid. The phosphatic 
calculi are stated to produce the most intense pain, and the urine is com- 
monly alkaline. The Roentgen rays are becoming of more and more value 
in determining the presence and position of a stone. 

Treatment. — In the attacks of renal colic great relief is experienced 
by the hot bath, which is sometimes sufficient to relax the spasm. When 
the pain is very intense morphia should be given hypodcrmieally, and in- 
halations of chloroform may be necessary until the effects of the anodyne 
are manifest. Local applications are sometimes grateful — hot poultices, 
or cloths wrung out of hot water. The patient may drink freely of hot 
lemonade, soda water, or barley water. Occasionally change in posture or 
inversion will give great relief. Surgical interference should be consid- 
ered in all cases, especially when the stone is large or the associated pye- 
litis severe. 



896 



DISEASES OF THE KIDNEYS. 



In the intervals the patient should, as far as possible, live a quiet life, 
avoiding sudden exertion of all sorts. The essential feature in the treat- 
ment is to keep the urine abundant and, in the uric-acid or uratic cases, 
alkaline. The patient should drink daily a large but definite quantity of 
mineral waters * or distilled water, which is just as satisfactory. The 
citrate or bicarbonate of potash may be added. The aching pains in the 
back are often greatly relieved by this treatment. Many patients find 
benefit from a stay at Saratoga, Bedford, Poland, or other mineral springs 
in this country, or at Vichy or Ems in Europe. 

The diet should be carefully regulated, and similar to that indicated in 
the early stages of gout. Sir William Eoberts recommends what is known 
as the solvent treatment for uric-acid calculi. The citrate of potash is 
given in large doses, half a drachm to a drachm, every three hours in a 
tumblerful of water. This should be kept up for several months. I have 
had no success with this treatment, nor, when one considers the character 
of the uric-acid stones usually met with in the kidney, does it seem likely 
that any solvent action could be exercised upon them by changes in the 
urine. This treatment should be abandoned if the urine becomes am- 
moniacal. 

The value of piperazine as a solvent of uric-acid gravel or of uric-acid 
stones has been much discussed of late. While outside the body a watery 
solution of the drug has this power in a marked degree, the amount ex- 
creted in the urine as given in the ordinary doses of 15 grains daily seems 
to have very little influence. Several observers have shown that the per- 
centage of piperazine excreted in the urine, when taken in doses of from 
1 to 2 grammes, has, when tested outside of the body, little or no influence 
as a solvent (Fawcett, Gordon). 



XII. TUMORS OF THE KIDNEY. 

These are benign and malignant. Of the benign tumors, the most 
common are the small nodular fibromata which occur frequently in the 
pyramids, the aberrant adrenals, which Grawitz has described, and occa- 
sionally lipoma, angioma, or lymphadenoma. The adenomata may be con- 
genital. In one of my cases the kidneys were greatly enlarged, contained 
small cysts, and numerous adenomatous structures throughout both organs. 

Malignant growths — cancer or sarcoma — may be either primary or sec- 
ondary. The sarcomata are the most common, either alveolar sarcoma or 
the remarkable form containing striped muscular fibres — rhabdo-myoma. 
They are very common tumors in children. G. Walker (Annals of Sur- 
gery, 1897) has analyzed the literature of the subject to date. Carcinoma 
is less frequent, and is of the encephaloid variety. 

The tumors attain a very large size. In one of my cases the left kidney 
weighed 12 pounds and almost filled the abdomen. In children they may 



* Some of these, if we judge by the laudatory reports, are as potent as the waters of 
Corsena, declared by Montaigne to be " powerful enough to break stones." 



TUMORS OF THE KIDNEY. 



897 



reach an enormous size. Morris states that in a boy at the Middlesex Hos- 
pital the tumor weighed 31 pounds. They grow rapidly, are often soft, 
and haemorrhage frequently takes place intq them. In the sarcomata, in- 
vasion of the pelvis or of the renal vein is common. The rhabdo-myomata 
rarely form very large tumors, and death occurs shortly after birth. In one 
of my cases the child lived to the age of three years and a half. The tumor 
grew into the renal vein and inferior cava. A detached fragment passed 
as an embolus into the pulmonary artery, and a portion of it blocked the 
tricuspid orifice. 

Symptoms. — The following are the most important: (1) Hasmaturia. 
This may be the first indication. The blood is fluid or clotted, and there 
may be very characteristic moulds of the pelvis of the kidney and of the 
ureter. It would no doubt be possible for such to form in the hematuria 
from calculus, but I have never met with a case of blood-casts of the pelvis 
and of the ureter, either alone or together, except in cancer. It is rare 
indeed that cancer elements can be recognized in the urine. 

(2) Pain is an uncertain symptom. In several of the largest tumors 
which have come under my observation there has been no discomfort from 
beginning to close. When present, it is of a dragging, dull character, situ- 
ated in the flank and radiating down the thigh. The passage of the clots 
may cause great pain. In a recent case the growth was at first upward, 
and the symptoms for some months were those of pleurisy. 

(3) Progressive emaciation. The loss of flesh is usually marked and 
advances rapidly. There may, however, be a very large tumor without 
emaciation. 

Physical Signs. — In almost all instances tumor is present. When 
small and on the right side, it may be very movable; in some instances, 
occupying a position in the iliac fossa, it has been mistaken for ovarian 
tumor. The large growths fill the flank and gradually extend toward the 
middle line, occupying the right or left half of the abdomen. Inspection 
may show two or three hemispherical projections corresponding to dis- 
tended sections of the organ. In children the abdomen may reach an 
enormous size and the veins are prominent and distended. On bimanual 
palpation the tumor is felt to occupy the lumbar region and can usually 
be lifted slightly from its bed; in some cases it is very movable, even when 
large; in others it is fixed, firm, and solid. The respiratory movements 
have but slight influence upon it. Eapidly growing renal tumors are soft, 
and on palpation may give a sense of fluctuation. A point of considerable 
importance is the fact that the colon crosses the tumor, and can usually be 
detected without difficulty. 

Diagnosis. — In children very large abdominal tumors are either renal 
or retroperitoneal. The retroperitoneal sarcoma (Lobstein's cancer) is more 
central, but may attain as large a size. If the case is seen only toward the 
end, a differential diagnosis may be impossible; but as a rule the sarcoma 
is less movable. It is to be remembered that these tumors may invade the 
kidney. On the left side an enlarged spleen is readily distinguished, as 
the edge is very distinct and the notch or notches well marked; it descends 
during respiration, and the colon lies behind, not in front of it. On the 
56 



898 



DISEASES OF THE KIDNEYS. 



right side growths of the liver are occasionally confounded with renal 
tumors; but such instances are rare, and there can usually be detected a 
zone of resonance between the upper margin of the renal tumor and the 
ribs. Late in the disease, however, this is not possible, for the renal tumor 
is in close union with the liver. 

A malignant growth in a movable kidney may be very deceptive and 
may simulate cancer of the ovary or myoma of the uterus. The great mo- 
bility upward of the renal growth and the negative result of examination 
of the pelvic viscera are the reliable points. 

Medicinal treatment is of no avail. When the growth is small and the 
patient in good condition removal of the organ may be undertaken, but the 
percentage of cases of recovery is very small, only 5.4 per cent (G-. Walker). 



XIII. CYSTIC DISEASE OF THE KIDNEY. 

The following varieties of cysts are met with: 

(1) The small cysts, already described in connection with the chronic 
nephritis, which result from dilatation of obstructed tubules or of Bow- 
man's capsules. There are cases very difficult to classify, in which the 
kidneys are greatly enlarged, and very cystic in middle-aged or elderly 
persons, and yet not so large as in the congenital form. 

(2) Solitary cysts, ranging in size from a marble to an orange, or even 
larger, are occasionally found in kidneys which present no other changes. 
In exceptional cases, they may form tumors of considerable size. Newman 
operated on one which contained 25 ounces of blood. They, too, in all 
probability, result from obstruction. 

(3) The congenital cystic kidneys. In this remarkable condition the 
kidneys are represented by a conglomeration of cysts, varying in size from 
a pea to a marble. The organs are greatly enlarged, and together may 
weigh 6 or more pounds. In the foetus they may attain a size sufficient 
to impede labor. Little or no renal tissue may be noticeable, although in 
microscopical sections it is seen that a considerable amount remains in 
the interspaces. The cysts contain a clear or turbid fluid, sometimes red- 
dish brown or even blackish in color, and may be of a colloidal consistence. 
Albumin, blood crystals, cholesterin, with triple phosphates and fat drops 
are found in the contents. Urea and uric acid are rarely present. The 
cysts are lined by a flattened epithelium. It is not yet accurately known 
how these cysts originate. That it is a defect in development rather than 
a pathological change is suggested by the fact that in the embryo it is often 
associated with other anomalies, particularly imperforate anus. Both Shat- 
tock and Bland Sutton, who have studied the question carefully, believe 
that the anomaly of development is in the failure of complete differentia- 
tion of the Wolffian bodies, but embryologists whom I have consulted tell 
me that this is most unlikely. Though the condition is congenital, yet from 
the history of certain cases it is evident that the organs must increase enor- 
mously in size. In a patient of Dr. Alfred King's, of Portland, Me., a 
man aged fifty-four, the abdomen presented nothing abnormal on careful 



CYSTIC DISEASE OF THE KIDNEY. 



899 



examination three years before his death, but three months prior to this 
date there were large bilateral tumors in the renal regions, which were 
readily diagnosed as cystic kidneys. The organs weighed 4 pounds each. 

In a large majority of the cases death occurs, either in utero or 'shortly 
after birth; but instances are met with at all ages up to fifty or sixty, and 
I see no reason to suppose that these are not examples of persistence of the 
congenital form. 

In the adult the tumors may be felt in the lumbar region as large 
rounded masses. 

The symptoms are those of chronic interstitial nephritis. Many of the 
cases have presented no indications whatever until a sudden attack of 
uraemia; others have died of heart-failure. A rare termination, as in a case 
at the University Hospital, Philadelphia, is the rupture of one of the 
cysts and the production of a perinephritic abscess. The cardio-vascular 
changes induced are similar to those of interstitial nephritis. The left 
ventricle is hypertrophied and the arterial tension is greatly increased. 
The condition is compatible with excellent health. Hematuria may occur. 
The dangers are those associated with chronic Bright's disease. It is im- 
portant to remember that the conglomerate cystic kidney is almost in- 
variably bilateral. One kidney may be somewhat larger and more cystic 
than the other. Bronzing of the skin may occur. 

Great enlargement of both organs, with hypertrophy of the left heart, 
increased arterial tension, and recurring attacks of hematuria, enable us 
to make a diagnosis. 

Operative interference is not justifiable. I know of an instance in 
which one kidney was removed and the patient died within twenty-four 
hours. 

(4) Occasionally the kidneys and liver present numerous small cysts 
scattered through the substance. The spleen and the thyroid also may 
be involved, and there may be congenital malformation of the heart. The 
cysts in the kidney are small, and neither so numerous nor so thickly set 
as in the conglomerate form, though in these cases the condition is prob- 
ably the result of some congenital defect. There are cases, however, in 
which the kidneys are very large. It is more common in the lower ani- 
mals than in man. I have seen several instances of it in the hog; in one 
case the liver weighed 40 pounds, and was converted into a mass of simple 
cysts. The kidneys were less involved. Charles Kennedy * states that he 
has found references to 12 cases of combined cystic disease of the liver and 
kidneys. 

The echinococcus cysts have been described under the section on para- 
sites. Paranephric cysts (external to the capsule) are rare; they may reach 
a large size. 



* Laboratory Reports of the Royal College of Physicians, Edinburgh, vol. iii. 



900 



DISEASES OF THE KIDNEYS. 



XIV. PERINEPHRIC ABSCESS. 

Suppuration in the connective tissue about the kidney may follow (1) 
blows and injuries; (2) the extension of inflammation from the pelvis of 
the kidney, the kidney itself, or the ureters; (3) perforation of the bowel, 
most commonly the appendix, in some instances the colon; (4) extension 
of suppuration from the spine, as in caries, or from the pleura, as in em- 
pyema; (5) as a sequel of the fevers, particularly in children. 

Post mortem the kidney is surrounded by pus, particularly at the pos- 
terior part, though the pus may lie altogether in front, between the kidney 
and the peritonaeum. Usually the abscess cavity is extensive. The pus 
is often offensive and may have a distinctly faecal odor from contact with 
the large bowel. It may burrow in various directions and burst into the 
pleura and be discharged through the lungs. A more frequent direction is 
down the psoas muscle, when it appears in the groin, or it may pass along 
the iliacus fascia and appear at Poupart's ligament. It may perforate the 
» bowel or rupture into the peritonaeum; sometimes it penetrates the bladder 
or vagina. 

Post mortem we occasionally find a condition of chronic perinephritis 
in which the fatty capsule of the kidney is extremely firm, with numerous 
bands of fibrous tissue, and is stripped off from the proper capsule with the 
greatest difficulty. Such a condition probably produces no symptoms. 

Symptoms. — There may be intense pain, aggravated by pressure, in 
the lumbar region. In other instances, the onset is insidious, without pain 
in the renal region; on examination signs of deep-seated suppuration may be 
detected. On the affected side there is usually pain, which may be referred 
to the neighborhood of the hip- joint or to the joint itself, or radiate down 
the thigh and be associated with retraction of the testis. The patient lies 
with the thigh flexed, so as to relax the psoas muscle, and in walking throws, 
as far as possible, the weight on the opposite leg. He also keeps the spine 
immobile, assumes a stooping posture in walking, and has great difficulty 
in voluntarily adducting the thigh (Gibney). 

There may be pus in the urine if the disease has extended from the 
pelvis or the kidney, but in other forms the urine is clear. When pus has 
formed there are usually chills with irregular fever and sweats. On ex- 
amination, deep-seated induration is felt between the last rib and the crest 
of the ilium. Bimanual palpation may reveal a distinct tumor mass. 
CEdema or puffmess of the skin is frequently present. 

The diagnosis is usually easy; when doubt exists the aspirator needle 
should be used. We cannot always differentiate the primary forms from 
those due to perforation of the kidney or of the bowel. This, however, makes 
but little difference, for the treatment is identical. It is usually possible by 
the history and examination to exclude diseases of the vertebra. In children 
hip-joint disease may be suspected, but the pain is higher, and there is no 
fulness or tenderness over the hip- joint itself. 

The treatment is clear — early, free, and permanent drainage. 



SECTION X. 



DISEASES OF THE NERVOUS SYSTEM. 



I. GENERAL INTRODUCTION. 

In diseases of the nervous system it is of the greatest importance to 
know accurately the position of the morbid process, and here, even more 
than in the other departments of medicine, a thorough knowledge of anat- 
omy and physiology is essential. For full details the student is referred to 
the text-books on the subject, as it is not possible to do more than touch on 
the subject in this place. 

Recent studies have modified our conceptions of the fundamental struc- 
ture of the nervous system. At present we think of it as a combination 
of an immense number of units, called neurones, all having an essentially 
similar structure. Each neurone is composed of a cell body, the protoplasmic 
processes or dendrites, and the axis-cylinder process or axone. The nutri- 
tion of the neurone depends in large part upon the condition of the cell 
body, and this in turn in all probability upon the activity of the nucleus. 
If the cell is injured in any manner the processes degenerate, or if the pro- 
cesses are separated from the cell they degenerate. Whether or not the 
neurones are organically connected with one another is still in dispute. The 
weight of evidence is in favor of complete anatomical and relative physio- 
logical independence. The terminals of the axone of one neurone are re- 
lated to the dendrites and cell bodies of other neurones by contact (Ramon 
y Cajal) or by concrescence (Held). It is generally admitted, however, that 
occasional coarse anastomoses exist between neighboring dendrites (accord- 
ing to Dogiel), especially in the retina. The studies of Apathy speak in 
favor of a general interconnection by means of neurofibrils and protoplasmic 
bridges. In general, it may be stated that the dendrites or protoplasmic 
processes conduct impulses toward the cell body (cellulipetal conduction), 
and the axis-cylinder process conducts them away from the cell (celltilifuga] 
conduction). The axis-cylinder process after leaving the cell gives off at 
varying intervals lateral branches called collaterals, which run ;i( right 
angles to the process. The collaterals and finally tin 1 axis-cylinder process 
itself at their terminations split up into many fine fibres, forming (he end- 
brushes. These, known as arborizations, surround the body of one or more 

901 



902 



DISEASES OF THE NERVOUS SYSTEM. 



of the many other cells, or interlace with their protoplasmic processes. The 
cell bodies of the neurones are collected more or less closely together in 
the gray matter of the brain and spinal cord and in the ganglia of the periph- 
eral nerves. Their processes, especially the axis-cylinder processes, run for 
the most part in the white tracts of the brain and spinal cord and in the 
peripheral nerves. In this way the different parts of the central nervous 
system are brought into relation with each other and with the rest of the 
body. In many cases the connections are extremely complicated and have 
only just begun to be unravelled, but, fortunately for the clinician, the 
nervous mechanism upon which motion depends is the best understood 
and is the simplest. 

A voluntary motor impulse starting from the brain cortex must pass 
through at least two neurones before it can reach the muscles, and we 
therefore speak of the motor tract as being composed of two segments — 
an upper and a lower. The neurones of the lower segment have the cell 
bodies and their protoplasmic processes in the different levels of the ventral 
horns of the spinal cord and in the motor nuclei of the cerebral nerves. 
The axis-cylinder processes of the lower motor neurones leave the spinal 
cord in the ventral roots and run in the peripheral nerves, to be distrib- 
uted to all the muscles of the body, where they end in arborizations in the 
motor end plates. These neurones are direct — that is, their cell bodies, 
their processes, and the muscles in which they end are all on the same side 
of the body.* 

The neurones of the upper motor segment have their cell bodies and 
protoplasmic processes in the cortex of the brain about the fissure of Ro- 
lando. Their axis-cylinder processes run in the white matter of the brain 
through the internal capsule and the cerebral peduncles into the pons, 
medulla, and cord, ending in arborizations around the protoplasmic pro- 
cesses and cell bodies of the lower motor neurones. The upper segment is, 
in the main, a crossed tract — that is to say, the neurones which compose it 
have their protoplasmic processes and cell bodies on one side of the body, 
whereas their axis-cylinder processes cross the middle line, to end about cell 
bodies of the lower motor neurones on the opposite side of the body. A 
certain number of the axones of the pyramidal tract, however, run to the 
lower motor neurones of the same side. 

Motor impulses starting in the left side of the brain cause contractions 
of muscles on the right side of the body, and those from the right side of 
the brain in muscles of the left side of the body. Leaving out of considera- 
tion the exceptions which have been mentioned, it may be stated as a gen- 
eral rule that the motor path is crossed, and that the crossing takes place 
in the upper segment (Figs. 1 and 2). Every muscular movement, even the 
simplest, requires the activity of many neurones. In the production of 
each movement special neurones are brought into play in a definite 
combination, and whenever these neurones act in this combination that 
specific movement is the result. In other words, all the movements of the 



* The root fibres of the nervus trochlearis and a portion of the root fibres of the 
nervus oculomotorius are well-known exceptions to this rule. 



GENERAL INTRODUCTION. 



903 



body are represented in the central nervous system by combinations of 
neurones — that is, they are localized. Muscular movements are localized in 
every part of the motor path, so that in cases of disease of the nervous sys- 
tem a study of the motor defect often enables one to fix upon the site of the 
process, and it would be hard to overesti- 
mate the importance of a thorough knowl- 
edge of such localization. 

The axis-cylinder processes of the lower 
motor neurones run in the peripheral nerves. 
Each nerve contains processes which are 
supplied to definite muscles, and we have 
in this way a peripheral localization. (See 
sections on Diseases of the Cerebral and 
Spinal Nerves.) 

The axis-cylinder processes which run in 
the peripheral nerves leave the central nerv- 
ous system from its ventral aspect. The 
ventral roots of the spinal cord are from 
above down, collected into small groups, 
which, after joining with the dorsal roots 
of the same level of the cord, leave the spinal 
canal between the vertebrae as the spinal 
nerves. That part of the cord from which 
the roots forming a single spinal nerve arise 
is called a segment, and corresponds to the 
nerve which arises from it and not to the 
vertebra to which it may be opposite. The 
axis-cylinder processes which go to make up 
any one peripheral nerve do not neces- 
sarily arise from the same segment of the 
spinal cord; in fact, most peripheral nerves 
contain processes from several often quite widely separated segments, and 
so it happens that the movements are represented in the spinal cord in a 
different manner — that is, there is spinal localization, or, better, lower level 
localization, since it also includes the motor nuclei of the cerebral nerves. 

Our knowledge of the localization of the muscular movements in the 
gray matter of the lower motor segment is far from complete, but enough 
is known to aid materially in determining the site of a spinal lesion. A 
number of tables have been prepared by different observers to represent 
our present knowledge of this subject. They differ from each other in 
minor details, but agree in the main. The following is the table prepared 
by Starr, in which the names of the muscles are given whose movements 
are re] (resented in each of the spinal segments. Movements, not muscles, 
are localized in the central nervous system, a point carefully to be borne in 
mind by the student (see Wichmann's Die Kuckenmarksnerven, etc., Berlin, 
1900). 




Fig. 1. — Diagram of motor path, 
showing the crossing of the 
path, which takes place in 
the upper segment. (Van Ge- 
huchten. colored.) 



904 



DISEASES OF THE NERVOUS SYSTEM. 




Pig. 2. — Diagram of motor path from right brain. The upper segment is black, the lower 
red. The nuclei of the motor cerebral nerves are shown on the left side : on the right 
side the cerebral nerves of that side are indicated. A lesion at 1 would cause upper 
segment paralysis in the arm of the opposite side — cerebral monoplegia; at 2, upper 
segment paralysis of the whole opposite side of the body — hemiplegia ; at 3, upper 
segment paralysis of the opposite face, arm, and leg, and lower segment paralysis 
of the eye muscles on the same side — crossed paralysis ; at 4, upper segment paraly- 
sis of opposite arm and leg, and lower segment paralysis of the face and the external 
rectus on the same side — crossed paralysis ; at 5, upper segment paralysis of all mus- 
cles below lesion, and lower segment paralysis of muscles represented at level of 
lesion — spinal paraplegia ; at 6, lower segment paralysis of muscles localized at seat 
of lesion — anterior poliomyelitis. (Van Gehuchten, modified.) 



GENERAL INTRODUCTION. 905 



Localization of the Functions of the Segments of the Spinal Cord. 



Segment. 


Muscles. 


Reflex. 


Sensation. 


II and 

III C. 


Sterno-mastoid. 
Trapezius. 
Scaleni and neck. 
Diaphragm. 


Hypochondrium (?). 

Sudden inspiration pro- 
duced by sudden press- 
ure beneath the lower 
border of ribs. 


Back of head to ver- 
tex. 
Neck. 


IV C. 


Diaphragm. 

Deltoid. 

Biceps. 

Coraco-brachialis. 
Supinator longus. 
Rhomboid. 

Supra- and infra-spinatus. 


Pupil. 4th to 7th cer- 
vical. 

Dilatation of the pupil 
produced by irritation 
of neck. 


Neck. 

Upper shoulder. 
Outer arm. 


V C. 


Deltoid. 
Biceps. 

Coraco-brachialis. 
Brachialis anticus. 
Supinator longus. 
Supinator brevis. 
Rhomboid. 
Teres minor. 

Pectoralis (clavicular part). 
Serratus magnus. 


Scapular. 

5th cervical to 1st thoracic. 

Irritation of skin over the 
scapula produces con- 
traction of the scapular 
muscles. 

Supinator longus. 

Tapping its tendon in 
wrist produces flexion 
of forearm. 


Back of shoulder and 
arm. 

Outer side of arm 
and forearm, front 
and back. 


VI C. 


Biceps. 

Brachialis anticus. 
Pectoralis (clavicular part). 
Serratus magnus. 
Triceps. 

Extensors of wrist and 

fingers. 
Pronators. 


Triceps. 

5th to 6th cervical. 
Tapping elbow tendon 

produces extension of 

forearm. 
Posterior wrist. 
6th to 8th cervical. 
Tapping tendons causes 

extension of hand. 


Outer side of fore- 
arm, front and 
back. 

Outer half of hand. 


VII C. 


Triceps (long head). 
Extensors of wrist and 

fingers. 
Pronators of wrist. 
Flexors of wrist. 
Subscapular. 
Pectoralis (costal part). 
Latissimus dorsi. 
Teres major. 


Anterior wrist. 
7th to 8th cervical. 
Tapping anterior tendons 

causes flexion of wrist. 
Palmar. 7th cervical to 

1st thoracic. 
Stroking palm causes 

closure of fingers. 


Inner side and back 
of arm and fore- 
arm. 

Radial half of the 
hand. 


VIII C. 


Flexors of wrist and fin- 
gers. 

Intrinsic muscles of hand. 




Forearm and hand, 
inner half. 


I T. 


Extensors of thumb. 
Intrinsic hand muscles. 
Thenar and hypothenar 
eminences. 




Forearm, inner half. 
Ulnar distribution to 
hand. 


II to 
XII T. 


Muscles of back and abdo- 
men. 
Erectores spinae. 


Epigastric. 4th to 7th 
thoracic. 

Tickling mammary re- 
gions causes retraction 
of epigastrium. 

Abdominal. 7th to 11th 
thoracic. 

Stroking side of abdomen 
causes retraction of 
belly. 


Skin of chest and 
abdomen in bands 
running around 
and downward, cor- 
responding to spi- 
nal nerves. 

Upper gluteal region. 



906 



DISEASES OF THE NERVOUS SYSTEM. 



Segment. 


Muscles. 




OH.i> OA X HJJ> . 


I L. 


Ilio-psoas. 
Sartorius. 

Muscles of abdomen. 


Cremasteric. 1st to 3d 

lumbar. 
Stroking inner thigh 

causes retraction of 

scrotum. 


Skin over groin and 
front of scrotum. 


II L. 


Ilio-psoas. Sartorius. 
Flexors of knee (Remak). 
Quadriceps femoris. 


Patellar tendon. 
Tapping tendon causes 
extension of leg. 


Outer side of thigh. 


Ill L. 


Quadriceps femoris. 
Inner rotators of thigh. 
Abductors of thigh. 




Front and inner side 
of thigh. 


IV L. 


Abductors of thigh. 
Adductors of thigh. 
Flexors of knee (Ferrier). 
Tibialis anticus. 


Gluteal. 4th to 5th lum- 
bar. 

Stroking buttock causes 
dimpling in fold of 
buttock. 


Inner side of thigh 

and leg to ankle. 
Inner side of foot. 


V L. 


Outward rotators of thigh. 
Flexors of knee (Ferrier). 
Flexors of ankle. 
Extensors of toes. 




Back of thigh, back 
of leg, and outer 
part of foot. 


I to II S. 


Flexors of ankle. 
Long flexor of toes. 
Peronasi. 

Intrinsic muscles of foot. 


Plantar. 

Tickling sole of foot 
causes flexion of toes 
and retraction of leg. 


Back of thigh. 
Leg and foot, outer 
side. 


Ill to 
VS. 


Perineal muscles. 


Foot reflex. Achilles 

tendon. 
Overextension of foot 

causes rapid flexion ; 

ankle-clonus. 
Bladder and rectal centres. 


Skin over sacrum. 
Anus. 

Perinaeum. Genitals. 



The above table refers only to localization in the spinal cord. The 
manner in which movements are represented in the pons and medulla is 
about as follows. This table is constructed from above downward in refer- 
ence to the motor nuclei of the cranial nerves: 



Nuclei. 
III. 



IV. 



" Sphincter. Ciliary muscles. 
Levator palpebral superioris. Rectus internus (in convergence). 
Rectus superior. Rectus inferior. 
Obliquus inferior. 
Obliquus superior. 
(Upper facial group.) 



Y i (Associated movement of levator palpebral) 
• I Muscles of lower jaw. 

f Rectus externus. Rectus 
VI. { inter, of opposite side 
in lateral movements. 

VII. — Facial muscles. 



J (Lower facial group). 
1 Muscles of tongue. 



IX. f Muscles of pharynx. 
X. -{ Muscles of oesophagus. 
XL L Muscles of larynx. 



GENERAL INTRODUCTION. 



907 



Cerebral Motor Localization. — The cell bodies of the upper motor neu- 
rones are found in the brain cortex about the fissure of Rolando, and it is in 
this region that we find the movements of the body again represented. 




The clinical studies of Hughlings Jackson, and the experiments of Hitzig 
and Fritsch, and of Ferrier, laid the foundation for the greal mass of 
most excellent work which has been done upon this subject. We owe much 



908 



DISEASES OF THE NERVOUS SYSTEM, 



to Victor Horsley and his associates for their careful work in this direc- 
tion, and the following description is based largely upon their writings, and 
especially upon the paper of Beevor and Horsley, in which they give the 
results of their experimental work on the orang-outang. Clinical observa- 
tion and electrical stimulation of the brain cortex during operations on 
human beings have confirmed the results of experiments upon animals. 

The motor area comprises the anterior central convolution, and to a less 
extent the posterior central convolution, the hinder part of the three frontal 

convolutions and the paracentral lobule. 
In the orang-outang and man not every 
part of this region is excitable by elec- 
trical stimulation. The movements are 
quite sharply localized, and there are in- 
excitable areas between the areas of repre- 
sentation of the larger divisions of the 
body. The diagram (Fig. 3) shows the 
centres as given by Beevor and Horsley. 
Certain landmarks are important. The 
genu of the fissure of Eolando, which 
when present in man is found at a point 
about midway or even higher between the 
upper margin of the hemisphere and the 
fissure of Sylvius, marks the boundary be- 
tween the area of representation of the 
arm from that of the face. The level of 
the superior frontal sulcus indicates the 
division of the leg from the arm area. 
From above down the areas of representa- 
tion occur in this order: leg, arm, face. 
Those of the leg and arm occupy the 
upper half of the convolution, and that 
for the face is spread out over the lower 
half. The diagram indicates the localiza- 
tion of the movements of the different 
parts of the extremities. 

The centres for the trunk are, accord- 
ing to Schafer, situated in the marginal gyrus just within the longitudinal 
fissure in the paracentral lobule. In man the motor speech centre is local- 
ized in the posterior part of the left inferior frontal convolution. 

The axis-cylinder processes of the upper motor neurones after leaving 
the gray matter of the motor cortex pass into the white matter of the brain 
and form part of the corona radiata. They converge and pass between 
the basal ganglia in the internal capsule. Here the motor axis-cylinders 
are collected into a compact bundle — the pyramidal tract — occupying the 
knee and anterior two thirds of the posterior limb of the internal capsule. 
The order in which the movements of the opposite side of the body are 
represented here is given in Fig. 4. 

After passing through the internal capsule the fibres of the pyramidal 




Fig. 4. — Diagram of motor and sen- 
sory representation in the inter- 
nal capsule. NL., Lenticular 
nucleus. NC, Caudate nucleus. 
THO., Optic thalamus. The 
motor paths are red and black, 
the sensory are blue. 



GENERAL INTRODUCTION. 



909 




Fig. 5. — Diagram of motor and sensory paths in Crura. 



tract leave the hemisphere by the crus, in which they occupy about the 
middle three fifths (Fig. 5). The movements of the tongue and lips are 
represented nearest the middle line. 

As soon as the tract enters the crus, some of its axis-cylinder processes 
leave it and cross the 
middle line to end in 
arborizations about the 
ganglion cells in the nu- 
cleus of the third nerve 
on the opposite side; and 
in this way, as the py- 
ramidal tract passes 
down, it gives off at dif- 
ferent levels fibres which 
end in the nuclei of all 
the motor cerebral nerves 
on the opposite side of 
the body. Some fibres, 
however, go to the nu- 
clei of the same side 

(Hoche). From the crus, the pyramidal tract runs through the pons and 
forms in the medulla oblongata the pyramid, which gives its name to the 
tract. At the lower part of the medulla, after the fibres going to the cere- 
bral nerves have crossed 
the middle line, a large 
proportion of the remain- 
ing fibres cross, decussat- 
ing with those from the 
opposite pyramid, and 
pass into the opposite side 
of the spinal cord, form- 
ing the crossed pyramidal 
tract of the lateral col- 
umn (fasciculus cerebro- 
spinalis lateralis) (Fig. 6, 
1). The smaller number 
of fibres which do not at 
this time cross, descend 
in the ventral column 
of the same side, form- 
ing the direct pyramidal 
tract, or Tiirck's column 
(fasciculus eerebrospinalis 
ventralis) (Fig. 6, 2). 

At every level of the 

spinal cord axis-cylinder processes leave the crossed pyramidal tract to enter 
the ventral horns and end about the cell bodies of the lower motor neurones. 
The tract diminishes in size from above downward. The fibres of the direct 




Fig. 6. — Diagram of cross-section of spinal cord, show- 
ing motor, red, and sensory, blue paths. 1, Lateral 
pyramidal tract. 2, Ventral pyramidal tract. 3, 
Dorsal columns. 4, Direct cerebellar tract. 5, 
Ventro-lateral ground bundles. 6, Ventro-lateral 
ascending tract of Growers. (Van Gehuchten, col- 
ored.) 




Fig. 7. — Diagram of skin areas corresponding to the different spinal segments. 
(Combined from Head's diagrams.) 



GENERAL INTRODUCTION. 



911 




Fig. 8. — Diagram of skin'areas corresponding to the different spinal segments. 
(Combined from Head's diagrams.) 



912 



DISEASES OF THE NERVOUS SYSTEM. 



pyramidal tract cross at different levels in the ventral white commissure, 
and also, it is believed, end about cells in the ventral horns on the opposite 
side of the cord. This tract usually ends about the middle of the thoracic 
region of the cord. 

The path for sensory conduction is more complicated than the motor 
path, and in its simplest form is composed of at least three sets of neurones, 
one above the other. The cell bodies of the lowest neurones are in the 
ganglia, on the dorsal roots of the spinal nerves, and the ganglia of 
the sensory cerebral nerves. These ganglion cells have a special form, 
having apparently but a single process, which, soon after leaving the cell, 
divides in a T-shaped manner, one portion running into the central nerv- 
ous system and the other to the periphery of the body. Embryological 
and comparative anatomical studies have made it probable that the periph- 
eral sensory fibre, the process which conducts toward the cell, represents 
the protoplasmic processes, while that which conducts away from the cell 
is the axis-cylinder process. In the peripheral sensory nerves we have, then, 
the dendrites of the lower sensory neurones. These start in the periphery 
of the body from their various specialized end organs. The axis-cylinder 
processes leave the ganglia and enter the spinal cord by the dorsal roots of 
the spinal nerves. After entering the cord each axis-cylinder process di- 
vides into an ascending and a descending branch, which run in the dorsal 
fasciculi. The descending branch runs but a short distance, and ends in 
the gray matter of the same side of the cord. It gives off a number of 
collaterals, which also end in the gray matter. The ascending branch may 
end in the gray matter soon after entering, or it may run in the dorsal fas- 
ciculi as far as the medulla, and end in the nuclei of these. In any case it 
does not cross the middle line. The lower sensory neurone is direct. 

The cells about which the axis-cylinder processes and their collaterals 
of the lower sensory neurone end are of various kinds. They are known 
as sensory neurones of the second order. In the first place, some of them 
end about the cell bodies of the lower motor neurones, forming the path 
for reflexes. They also end about cells whose axis-cylinder processes cross 
the middle line and run to the opposite side of the brain. In the spinal 
cord these cells are found in the different parts of the gray matter, and their 
axis-cylinder processes run in the opposite ventro-lateral ascending tract 
of dowers (Fig. 6, 6) and in the ground bundles (fasciculus lateralis pro- 
prius and fasciculus ventralis proprius). 

In the medulla the nuclei of the dorsal fasciculi (nucleus fasciculi gra- 
cilis (Grolli) and nucleus fasciculi cuneati (Burdachi)) contain for the most 
part cells of this character. Their axis-cylinder processes, after crossing, 
run toward the brain in the medial lemniscus or bundle of the fillet; certain 
of the longitudinal bundles in the formatio reticularis also represent sensory 
paths from the spinal cord and medulla toward higher centres. The fibres 
of the medial lemniscus or fillet do not, however, run directly to the cere- 
bral cortex. They end about cells in the ventro-lateral portion of the optic 
thalamus, and the tract is continued on by way of another set of neurones, 
which send processes to end in the cortex of the central convolutions and 
the parietal lobe. This is the most direct path of sensory conduction, 



GENERAL INTRODUCTION. 



913 



but by no means the only one. The peripheral sensory neurones may 
also end about cells in the cord whose axones run but a short distance 
toward the brain before ending again in the gray matter, and the path, if 
path it can be called, is made up of a series of these superimposed neurones. 
The gray matter of the cord itself is also believed to offer paths of sensory 
conduction. All these paths reach the tegmentum and optic thalamus, and 
from thence are distributed to the cortex along with the other sensory paths. 
There may also be paths of sensory conduction through the cerebellum by 
way of the direct cerebellar tract and Gowers' bundle. From this short 
summary it is evident that the possible paths of sensory conduction are 
many, and that our knowledge of them is as yet very indefinite; for this 
reason disturbances in sensation do not give us as much help in making 
a local diagnosis as do those of motion. Certain facts are important to keep 
in mind. The different peripheral nerves contain sensory fibres from defi- 
nite areas of the skin, and upon this depends the peripheral sensory repre- 
sentation. (See section on Diseases of the Spinal Nerves.) 

The sensory areas of the skin are represented in the spinal cord in an 
entirely different manner from the peripheral representation, just as is the 
case in regard to motion. The surface of the body has been mapped out 
into areas which are meant to correspond to the different dorsal roots or 
spinal segments. In Starr's table the third column indicates his belief. 
His more recent division of the sensory areas on the limbs is pictured in 
the American Journal of the Medical Sciences, June, 1895. Figs. 7 and 8 
embody the result of Head's work. They are also the areas in which the 
referred pain and cutaneous tenderness in visceral diseases make their ap- 
pearance. The cutaneous sensory impressions are in man conducted toward 
the brain, probably on the opposite side of the cord — that is, the path crosses 
to the opposite side soon after entering the cord. Muscular sense, on the 
other hand, is conducted on the same side of the cord in the fasciculi of 
Goll, to cross above by means of the axones of sensory neurones of the second 
order in the medulla. 

The localization of sensory impressions in the cortex of the brain is not 
definitely determined, but in a general way it corresponds to the motor repre- 
sentation. Sensation seems, however, to be more widely represented than 
motion, and to occupy most of the parietal lobe as well as the central con- 
volutions. 

The paths for the conduction of the stimuli which underlie the special 
senses are given in the section upon the cerebral nerves, and it is only neces- 
sary here to refer to what is known of the cortical representation of these 
senses. 

Visual impressions are localized in the occipital lobes. The primary 
visual centre is on the mesial surface in the cuneus, especially about the 
calcarine fissure, and here are represented the opposite half-visual fields. 
Some authors believe that there is another higher centre on the outer sur- 
face of the occipital lobe, in which the vision of the opposite eye is chiefly 
represented. However this may be, most authors hold that the angular 
gyrus of the left hemisphere is a part of the brain in which are stored the 
memories of the meaning of letters, words, figures, and indeed of all seen 
57 



914 



DISEASES OF THE NERVOUS SYSTEM. 



objects. This is designated in the visual speech centre on the diagram 
(Fig. 3). Flechsig and Monakow do not admit this. 

Auditory impressions are localized for the most part in the first tem- 
poral convolution and the transverse temporal gyri, and it is in this region 
in the left hemisphere that the memories of the meanings of heard words 
and sounds are stored. Musical memories are localized somewhat in front 
of those for words (Fig. 3). The cortical centres for smell include a part of 
the base of the frontal lobe, the uncus, and perhaps the gyrus hippocampi. 
The centres for taste are supposed to be situated near those for smell, but 
we possess as yet no definite information about them. 

Topical Diagnosis. — The successful diagnosis of the position of 
a lesion in the nervous system depends upon a careful and exhaustive 
examination into all the symptoms that are present, and then endeavoring 
with the help of anatomy and physiology to determine the place, a disturb- 
ance at which might produce these symptoms. 

The abnormalities of motion are usually the most important localizing 
symptoms, both on account of the ease with which they can be demon- 
strated, and also because of the comparative accuracy of our knowledge of 
the motor path. 

Lesions in any part of the motor path cause disturbances of motion. If 
destructive, the function of the part is abolished, and as the result there 
is paralysis. If, on the other hand, the lesion is an irritative one, the 
structures are thrown into abnormal activity, which produces abnormal 
muscular contraction. The character of the paralysis or of the abnormal 
muscular contraction varies with lesions of the upper and lower motor seg- 
ment, the variations depending, first, upon the anatomical position of the 
two segments; and, secondly, upon the symptoms which are the result of 
secondary degeneration in each of the segments. 

(a) Lesions of the Lower or Spino-muscular Segment. — Destructive 
Lesions. — It has been stated above that the nutrition of all parts of a neu- 
rone depends upon their connection with its healthy cell body; and if the 
cell body be injured, its processes undergo degeneration, or if a portion 
of a process be separated from the cell body, that part degenerates along 
its whole length. This so-called secondary degeneration plays a very impor- 
tant role in the symptomatology. 

In the lower motor segment the degeneration not only affects the axis- 
cylinder processes which run in the peripheral nerves, but also the muscle 
fibres in which the axis-cylinder processes end. The degeneration of the 
nerves and muscles is made evident, first, by the muscles becoming smaller 
and flabby, and, secondly, by change in their reaction to electrical stimula- 
tion. The degenerated nerve gives no response to either the galvanic or 
the faradic current, and the muscle does not respond to faradic stimula- 
tion, but reacts in a characteristic manner to the galvanic current. The 
contraction, instead of being sharp, quick, lightning-like, as in that of a 
normal muscle, is slow and lazy, and is often produced by a weaker current, 
and the anode-closing contraction may be greater than the cathode-closing 
contraction. This is the reaction of degeneration, but it is not always pres- 
ent in the classical form. The essential feature is the slow, lazy contrae- 



GENERAL INTRODUCTION. 915 

tion of the muscle to the galvanic current, and when this is present the 
muscle is degenerated. 

The myotatic irritability, or muscle reflex, and the muscle tonus de- 
pend upon the integrity of the reflex arc, of which the lower motor seg- 
ment is the efferent limb, and in a paralysis due to lesion of this segment 
the muscle reflexes (tendon reflexes) are abolished and there is a diminished 
muscular tension. 

Lower segment paralyses have for their characteristics degenerative 
atrophy with the reaction of degeneration in the affected muscles, loss of 
their reflex excitability, and a diminished muscular tension. These are 
the general characteristics, but the anatomical relations of this segment 
also give certain peculiarities in the distribution of the paralyses which 
help to distinguish them from those which follow lesions of the upper seg- 
ment, and which also aid in determining the site of the lesion in the lower 
segment itself. The cell bodies of this segment are distributed in groups, 
from the level of the peduncles of the brain throughout the whole extent 
of the spinal cord to its termination opposite the second lumbar vertebra, 
and their axis-cylinder processes run in the peripheral nerves to every mus- 
cle in the body; so that the component parts are more or less widely sepa- 
rated from each other, and a local lesion causes paralysis of only a few 
muscles or groups of muscles, and not of a whole section of the body, as 
is the case where lesions affect the upper segment. The muscles which 
are paralyzed indicate whether the disease is in the peripheral nerves or 
spinal cord; for, as we have seen above, the muscles are represented differ- 
ently in the peripheral nerves and in the spinal cord. Sensory symptoms, 
which may accompany the paralysis, are often of great assistance in making 
a local diagnosis. Thus, in a paralysis with the characteristics of a lesion 
of the lower motor segment, if the paralyzed muscles are all supplied by 
one nerve, and the anaesthetic area of the skin is supplied by that nerve, 
it is evident that the lesion must be in the nerve itself. On the other hand, 
if the muscles paralyzed are not supplied by a single nerve, but are repre- 
sented close together in the spinal cord, and the anaesthetic area corresponds 
to that section of the cord (see table), it is equally clear that the lesion must 
be in the cord itself or in its nerve roots. 

Irritative Lesions of the Lower Motor Segment.— Lesions of this seg- 
ment cause comparatively few symptoms of irritation, and our knowledge 
on the point is neither extensive nor accurate. The fibrillary contractions 
which are so common in muscles undergoing degeneration are probably 
due to stimulation of the cell bodies in their slow degeneration, as in pro- 
gressive muscular atrophy, or to irritation of the axis-cylinder processes 
in the peripheral nerves, as in neuritis. Lesions which affect the motor 
roots as they leave the central nervous system may cause spasmodic con- 
tractions in the muscles supplied by them. Certain convulsive paroxysms, 
of which laryngismus stridulus is a type, and to which the spasms of tetany 
also belong, are believed to be due to abnormal activity in the lower motor 
centres. These are the " lowest level fits " of llughlings Jackson. Cer- 
tain poisons, as strychnia and that of tetanus, act particularly upon these 
centres. 



916 DISEASES OF THE NERVOUS SYSTEM. 

The principle diseases in which the lower motor segment may be in- 
volved are: all diseases involving the peripheral nerves, cerebral and spinal 
meningitis, injuries, haemorrhages and tumors of the medulla and cord or 
their membranes, lesions of the gray matter of the segment, anterior polio- 
myelitis, progressive muscular atrophy, bulbar paralysis, ophthalmoplegia, 
syringo-myelia, etc. 

(V) Lesions of the Upper Motor Segment. — Destructive lesions cause, as 
in the lower motor segment, paralysis, and here again the secondary degen- 
eration which follows the lesion gives to the paralysis its distinctive char- 
acteristics. In this case the paralysis is accompanied by a spastic condi- 
tion, shown in an exaggeration of muscle reflex and an increase in the ten- 
sion of the muscle. It is not accurately known how the degeneration of 
the pyramidal fibres causes this excess of the muscle reflex. The usual ex- 
planation is, that under normal circumstances the upper motor centres 
are constantly exerting a restraining influence upon the activity of the 
lower centres, and that when the influence ceases to act, on account of dis- 
ease of the pyramidal fibres, the latter take on increased activity, which is 
made manifest by an exaggeration of the muscle reflex. 

We have seen that the neurones composing each segment of the motor 
path are to be considered as nutritional units, and therefore the secondary 
degeneration in the upper segment stops at the beginning of the lower. 
For this reason the muscles paralyzed from lesions in the upper segment do 
not undergo degenerative atrophy, nor do they show any marked change 
in their electrical reactions. 

The separate parts of the upper motor segment lie much more closely 
together than do those of the lower segment, and therefore a small lesion 
may cause paralysis in many muscles. This is more particularly true in 
the internal capsule, where all the axis-cylinder processes of this segment 
are collected into a compact bundle — the pyramidal tract. A lesion in 
this region usually causes paralysis of most of the muscles on the opposite 
side of the body — that is, hemiplegia. The pyramidal tract continues in a 
compact bundle, giving off fibres to the motor nuclei at different levels; a 
lesion anywhere in its course is followed by paralysis of all the muscles 
whose nuclei are situated below the lesion. When the disease is above the 
decussation, the paralysis is on the opposite side of the body; when below," 
the paralyzed muscles are on the same side as the lesion. Above the in- 
ternal capsule the path is somewhat more separated, and in the cortex the 
centres for the movements of the different sections of the body are com- 
paratively far apart, and a sharply localized lesion in this region may cause 
a more limited paralysis, affecting a limb or a segment of a limb — the cere- 
bral monoplegias; but even here the paralysis is not confined to an indi- 
vidual muscle or group of muscles, as is commonly the case in lower seg- 
ment paralysis (see Fig. 2 and explanation). 

To sum up, the paralyses due to lesions of the upper motor segment 
are widespread, often hemiplegic; the paralyzed muscles are spastic (the 
tendon reflexes exaggerated), they do not undergo degenerative atrophy, 
and they do not present the degenerative reaction to electrical stimulation. 

There is an exception to the above statement — that is, in the paralyses 



GENERAL INTRODUCTION. 



917 



which follow a complete transverse lesion of the spinal cord. Here the 
limbs are of course completely paralyzed, but instead of being spastic they 
are flaccid and the deep reflexes are absent. There is, however, no marked 
atrophy in the muscles, and they react normally to electricity. There is 
no satisfactory explanation of why the reflexes should be abolished under 
these conditions. 

Irritative Lesions of the Upper Motor Segment. — Our knowledge of 
such lesions is confined for the most part to those acting on the motor cor- 
tex. The abnormal muscular contractions resulting from lesions so situ- 
ated have as their type the localized convulsive seizures classed under Jack- 
sonian or cortical epilepsy, which are characterized by the convulsion begin- 
ning in a single muscle or group of muscles and involving other muscles 
in a definite order, depending upon the position of their representation in 
the cortex. For instance, such a convulsion, beginning in the muscles of 
the face, next involves those of the arm and hand, and then the leg. The 
convulsion is usually accompanied by sensory phenomena and followed by 
a weakness of the muscles involved. 

A majority of lesions of the motor cortex are both destructive and irri- 
tative — i. e., they destroy the nerve cells of a certain centre, and either in 
their growth or by their presence throw into abnormal activity those of the 
surrounding centres. 

The upper motor segment is involved in nearly all the diseases of 
the brain and spinal cord, especially in injuries, tumors, abscesses, and 
haemorrhages; transverse lesions of the cord; syringomyelia, progres- 
sive muscular atrophy, bulbar paralysis, etc. One lesion often involves 
both the upper and the lower motor segments, and we have paralysis in 
the different parts of the body, with the characteristics of each. Such 
a combination enables us in many cases to make an accurate local diag- 
nosis. 

Lesions in the optic path and in the different speech centres also give 
localizing symptoms, which should be always looked for. 

(c) Lesions of the Sensory Path.— Here again the lesion may be either 
irritative or destructive. Irritative lesions cause abnormal subjective sen- 
sory impressions — paresthesia, formication, a sense of cold or constriction, 
and pain of every grade of intensity. The character of the sensory symp- 
toms gives very little indication as to the position of the irritating process. 
Intense pain is, as a rule, a symptom of a lesion in the peripheral sensory 
neurones, but it may be caused by a disease of the sensory path within the 
central nervous system. 

The exact distribution of symptoms gives us more accurate data, for if 
they are confined to the distribution of a peripheral nerve or of a spinal 
segment the indication is plain. If one side of the body is more or less 
completely affected, we must think of a lesion somewhere within the 
brain, etc. 

Destructive Lesions. — A complete destruction of the sensory paths from 
any part of the body would of course deprive that part of sensation in all 
its qualities. This occurs most frequently from injury to the peripheral 
sensory neurones within the peripheral nerves, and the area of anaesthesia 



918 



DISEASES OF THE NERVOUS SYSTEM. 



depends upon the nerve injured. Complete transverse lesion of the cord 
causes complete anaesthesia below the injury. 

Unilateral lesions of the cord, medulla, dorsal part of the pons, teg- 
mentum, thalamus, internal capsule, and cortex cause disturbances of sensa- 
tion on the opposite side of the body; here again the extent of the defect 
more than its character helps us to determine the position of the lesion. 
Hemianesthesia involving the face as well as the rest of the body can only 
occur above the place where the sensory paths from the fifth nerve have 
crossed the middle line on their way to the cortex. This is in the upper 
part of the pons. From this point to where they leave the internal cap- 
sule the sensory paths are in fairly close relation, and are at times involved 
in a very small lesion. Above the internal capsule the paths diverge 
quickly, and for this reason only an extensive lesion can involve them all, 
and in lesions of this part we are more apt to have the sensory disturbances 
confined to one or the other segments of the body. Unilateral lesions of 
the pons, medulla, and cord usually cause sensory disturbances on the same 
side of the body, as well as those on the opposite side. These are due to 
the involvement of the sensory paths as they enter the central nervous sys- 
tem at or a little below the site of the lesion and before the axones of the 
sensoryneurones of the second order have crossed the middle line. The area 
of disturbed sensation on the same side is limited to the distribution of one 
or more spinal segments and often indicates accurately the position and ex- 
tent of the diseased process. As a rule, destructive lesions of the central 
nervous system do not involve all the paths of sensory conduction, and the 
loss of sensation is not complete. It is often astonishing how very slight the 
sensory disturbances are which result from an extensive lesion of the nerv- 
ous system. Sensation may be diminished in all of its qualities, or, what is 
more common, certain qualities may be affected while others are normal. 
These cases of dissociation of sensation, or so-called elective sensory paraly- 
sis, have been much studied of late. Thus the sense of pain and tempera- 
ture may be lost while that of touch remains normal, as is often the case in 
diseases of the spinal cord, or there may be simply a loss of the muscular 
sense and of the stereognostic sense (the complex sensory impression which 
enables one to recognize an object placed in the hand), as occurs frequently 
from lesions of the cortex. Occasionally pain sensation persists with loss 
of tactile and thermic sensations. Almost every other combination has 
been described. It is the distribution more than the character of the sensory 
defect that is of importance, and often the distribution gives but uncertain 
indication of the position of the lesion. The combination of the sensory 
defect with different forms of paralysis gives the most certain diagnostic 
signs. The student is referred to the sections on the individual parts of 
the nervous system for a more detailed consideration of the subject. 



INTRODUCTION. 



919 



II. SYSTEM DISEASES. 
I. INTRODUCTION. 

There are certain diseases of the nervous system which are confined, 
if not absolutely, still in great part, to definite tracts (combinations of 
neurones) which subserve like functions. These tracts are called sys- 
tems, and a disease which is confined to one of them is a system disease. 
If more than one system is involved, the process is called a combined system 
disease. Just what diseases should be classed under these names has given 
rise to much discussion but to very little agreement. We cannot speak 
positively; our knowledge is as yet not sufficiently accurate, either in regard 
to the exact limits of the systems themselves, or to the nature and extent 
of the morbid process in the several diseases. In the classification which 
has been adopted in this edition the endeavor has been to make the arrange- 
ment as simple as possible, and, while it is based upon what is believed to 
be the best founded views of the systems and their diseases, there has been 
no attempt to carry the classification to its logical conclusion, nor have the 
limits of the theory been always respected. 

In general it may be said that the nervous system is composed of two 
great systems of neurones, the afferent or sensory system and the efferent 
or motor system, and the connections between them. (See General Intro- 
duction.) 

Locomotor ataxia is a disease confined to the afferent system, and pro- 
gressive muscular atrophy is one of the efferent system. Eepresenting typ- 
ical system diseases as we now understand them, they have been taken as 
the basis of the classification. Several theories have been advanced to ex- 
plain why a disease should be limited to a definite system of neurones. One 
view is based upon the idea that in certain individuals one or the other of 
these systems has an innate tendency to undergo degeneration; another as- 
sumes that neurones with a similar function have a similar chemical con- 
struction (which differs from that of neurones with a different function), 
and this is taken to explain why a poison circulating in the blood should 
show a selective action for a single functional system of neurones. 

In the afferent tract locomotor ataxia stands alone as a system disease. 
In the efferent tract progressive (central) muscular atrophy is the chief 
representative, as in it the whole motor path is more or less involved. The- 
oretically, primary lateral sclerosis is a disease confined to the upper seg- 
ment of the efferent tract, while anterior poliomyelitis involves the lower 
segment of the tract. 

In connection with progressive (central) muscular atrophy, the other 
forms of muscular atrophy are considered as a matter of convenience. In 
other instances, too, diseases are arranged in positions to which they might 
not be entitled, had a rigid classification of system diseases been maintained. 



920 



DISEASES OF THE NERVOUS SYSTEM. 



II. DISEASES OF THE AFFERENT OR SENSORY SYSTEM. 

Locomotok Ataxia 
{Tales Dorsalis; Posterior Spinal Sclerosis). 

Definition. — An affection characterized clinically by incoordination, 
sensory and trophic disturbances, and involvement of the special senses, 
particularly the eyes. Anatomically there are found degeneration of the 
posterior roots and of the dorsal columns of the cord; sometimes the spinal 
ganglia and peripheral nerves are affected. Foci of degeneration in the 
basal ganglia and degenerative changes in the cortex cerebri have been 
described. 

Etiology. — It is a widespread disease, more frequent in cities than in 
the country. The relative proportion may be judged from the fact that 
of 8,642 cases in the neurological dispensary of the Johns Hopkins Hos- 
pital there were 89 cases of locomotor ataxia (H. M. Thomas). Males are 
attacked more frequently than females, the proportion being at least 10 to 
1. Mitchell has called attention to the fact that it is a rare disease in 
the negro. It is a disease of adult life, a majority of the cases occurring 
between the thirtieth and fortieth years. Occasionally cases are seen in 
young men. The form of ataxia which occurs in children is a different dis- 
ease. Of special causes syphilis is the most important. According to the 
figures of Erb, Fournier, and Growers, in from 50 to 75 per cent of all cases 
there is a history of this disease. Erb's recent figures are most striking; 
of 300 cases of tabes in private practice 89 per cent had had syphilis. Moe- 
bius goes so far as to say, " The longer I reflect upon it, the more firmly I 
believe that tabes never originates without syphilis." 

Excessive fatigue, overexertion, injury, exposure to cold and wet, and 
sexual excesses are all assigned as causes. There are instances in which 
the disease has closely followed severe exposure. James Stewart has noted 
that the Ottawa lumbermen, who live a very hard life in the camps during 
the winter months, are frequently the subjects of locomotor ataxia. Trauma 
has been noted in a few cases. Alcoholic excess does not seem to predis- 
pose to the disease. Among patients in the better classes of life I do not 
remember one in which there had been a previous history of prolonged 
drunkenness. There are now a good many cases on record of the existence 
of the disease in both husband and wife. 

Morbid Anatomy and Pathology. — Our conception of tabes 
dorsalis has undergone radical alteration, and the studies of Leyden, Eed- 
lich, Marie, and others have shown that it can no longer be regarded as a 
primary sclerosis of the dorsal columns. These, it will be remembered, are 
made up, in great part, of the axis-cylinder processes of the spinal ganglia, 
and they, with their branches, represent in the cord the paths of sensory 
conduction. The peripheral sensory nerves represent the protoplasmic 
processes of the spinal ganglia, which important structures are the trophic 
centres both for the sensory nerves as well as for the axis-cylinder processes 
which make up the dorsal columns of the cord. Marie calls attention also 



DISEASES OF THE AFFERENT OR SENSORY SYSTEM. 



921 



to the possibility of the existence of peripheral or terminal ganglion cells 
which are found in different organs — cells from which certain of the sensory 
fibres are derived which go to form the dorsal nerve-roots. According to 
the general laws of nerve physiology, already mentioned, lesions of the nerve 
ganglia would be followed by degeneration of the dorsal root-fibres and of 
their continuation in the cord, and this is practically what the recent theory 
of tabes involves. The changes in the dorsal columns are merely a se- 
quence, and not the primary disease. The fibres of the dorsal root are di- 
vided into three sets: 

(1) The short fibres, which pass almost directly into the dorsal cornu 
after entering the cord. 

(2) Fibres of moderate length, which run upward in the cord; some 
of them enter the dorsal horn at its middle part, while others pass into 
Clarke's column. The fibres of this group run in the fasciculus cuneatus 
of Burdach. 

(3) A group of long fibres, which are derived chiefly from the roots of 
the cauda equina, and which pass the whole length of the cord to enter 
certain nuclei in the medulla. They form the fasciculus gracilis of 
Goll. 

The initial cord lesion in tabes is found in the dorsal root-zone and 
in the zone or tract of Lissauer, a narrow portion situated between the 
margin of the cord and the apex of the posterior horn. In the fasciculus 
of Burdach the sclerosis is in almost direct proportion to the duration of the 
disease, slight at first and centrally placed, and becoming widespread as 
the disease advances. The fasciculus of Goll is affected slightly in the early 
stages, but in the advanced stage there is extensive sclerosis. Marie cor- 
relates the sclerosis of these different parts with the different groups of 
nerve-fibres of the dorsal root, the dorsal root-zone and the zone of Lis- 
sauer degenerating from the involvement of the short fibres; the sclerosis 
of the fasciculi of Burdach and the disappearance of the network of the 
nerve-fibres in the column of Clarke being due to the degeneration of the 
second group, the fibres of moderate length; while the sclerosis of the fas- 
ciculi of Goll is caused by the degeneration of the third group, namely, the 
long fibres. He suggests also that groups of fibres in the different dorsal 
roots are not simultaneously affected, and the lesions may be in an ad- 
vanced stage in one region and but slight in the other. " The lesions of the 
spinal cord in tabes occur by segments, each dorsal root bringing into the 
dorsal column a fresh contingent of degenerated fibres." 

According to this interesting hypothesis the lesions of the ganglia of 
the dorsal roots are responsible, in part at least, for the peripheral neuritis, 
since in degeneration of the spinal ganglia and consequent loss of trophic 
influence there would necessarily be degeneration in the peripheral nerve- 
trunks. Possibly, too, Marie suggests, the degeneration of the peripheral 
ganglion cells may have a good deal to do with the neuritis of tabes. 

Obersteiner and Redlich, while agreeing that the degeneration of the 
dorsal columns of the cord is dependent upon a disease in the dorsal roots, 
believe, at least for most cases, that the change in the latter is secondary to 
a chronic inflammation of the pia mater, which, by making pressure on the 
58 



922 



DISEASES OF THE NERVOUS SYSTEM. 



dorsal root-fibres gust where they are poor in myeline, causes them to de- 
generate. 

The spinal ganglia have been found diseased in certain cases, but in 
other cases no change whatever could be detected, even by the aid of the 
most delicate technique, and Marie acknowledges that there is very little 
anatomical proof for his theory that it is these structures that are primarily 
affected in tabes. 

Trepinski has divided the dorsal fasciculi into different systems accord- 
ing to the time of the development of their myeline, and has endeavored 
to show that the sclerosis in tabes follows these systems. 

Symptoms. — These are best considered under three stages — the in- 
cipient stage, the ataxic stage, and the paralytic stage. 

The Incipient Stage. — This is sometimes called the preataxic stage. 
The manner in which tabes makes its onset differs very widely in the dif- 
ferent cases, and mistakes in diagnosis are often made early in the disease. 
The following are the most characteristic initial symptoms: 

Pains, usually of a sharp stabbing character; hence the term lightning 
pains. They last for only a second or two and are most common in the legs. 
They may be associated with a hot burning feeling. Occasionally herpes 
may develop at the site of the pain. They may occur at irregular intervals, 
and are more prone to follow excesses or to come on when health is im- 
paired. The gastric crises and other crises may occur in the disease. 
Paresthesia may also be among the first symptoms. Numbness of the feet, 
tingling, etc., and at times a sense of constriction about the body. 

Ocular Symptoms. — (a) Optic atrophy. This occurs in about 10 per cent 
of the cases, and is often an early and even the first symptom. There is 
a gradual loss of vision, which in a large majority of cases leads to total 
blindness, (b) Ptosis, which may be double or single, (c) Paralysis of the 
external muscles of the eye. This may be of a single muscle or occasion- 
ally of all of the muscles of the eye. The paralysis is often transient, the 
patient merely complaining that he saw double for a certain period, (d) 
Argyll Robertson pupil, in which there is loss of the iris reflex to light 
but contraction during accommodation. The pupils are often very small — 
spinal myosis. 

Bladder Symptoms. — The first warning of the disease which the patient 
has may be a certain difficulty in emptying the bladder. Incontinence of 
urine occurs only at a later stage of the disease. Decrease in sexual desire 
and power may also be an early symptom. 

Trophic Disturbances. — These usually occur later in the disease, but at 
times they are very early symptoms and it is not very infrequent to have 
one's attention called to the trouble by the presence of a perforating ulcer 
or of a characteristic Charcot's joint. 

Loss of the Knee-jerk. — This early and most important symptom may 
occur years before the development of ataxia. Even alone it is of great mo- 
ment, since it is very rare to meet with individuals in whom the knee-jerk 
is normally absent. The combination of loss of the knee-kick with one 
or more of the symptoms mentioned above, especially with the lightning 
pains and ptosis or Argyll Robertson pupil, is practically diagnostic. The 



DISEASES OF THE AFFERENT OR SENSORY SYSTEM. 



923 



knee-jerk is not lost suddenly, but gradually decreases, often disappearing 
in one leg before the other. 

These are the most common symptoms of the initial stage of tabes and 
may persist for years without the development of incoordination. The pa- 
tient may look well and feel well, and be troubled only by occasional 
attacks of lightning pains or of one of the other subjective symptoms. 
Moebius goes so far as to state that the typical Argyll Eobertson pupil 
means either tabes or general paralysis, and that paralysis of the external 
muscles of the eye developing in adults are of almost equal importance, es- 
pecially if they develop painlessly. 

The time between the syphilitic infection and the occurrence of the 
first symptoms of locomotor ataxia varies within wide limits. About one 
half the cases occur between the sixth and fifteenth year, but many begin 
even later than this. 

The disease may never progress beyond this stage, and when optic 
atrophy develops early and leads to blindness, ataxia rarely, if ever, super- 
venes. There is a sort of antagonism between the ocular symptoms and 
the progress of the ataxia. Charcot laid considerable stress upon this, and 
both Dejerine and Spiller have since emphasized the point. 

Ataxic Stage. — Motor Symptoms. — The ataxia is believed to be due to 
a disturbance or loss of the afferent impulses from the muscles, joints and 
deep tissues, and a disturbance of the muscle sense itself can usually be 
demonstrated. It develops gradually. One of the first indications to the 
patient is inability to get about readily in the dark or to maintain his equi- 
librium when washing his face with the eyes shut. When the patient stands 
with the feet together and the eyes closed, he sways and has difficulty in 
maintaining his position (Romberg's symptom), and he may be quite un- 
able to stand on one leg. He does not start off promptly at the word 
of command. On turning quickly he is apt to fall. He descends stairs 
with more difficulty than he ascends them. Gradually the characteristic 
ataxic gait develops. The patient, as a rule, walks with a stick, the eyes 
are directed to the ground, the body is thrown forward, and the legs are 
wide apart. In walking, the leg is thrown out violently, the foot is raised 
too high and is brought down in a stamping manner with the heel first, or 
the whole sole comes in contact with the ground. Ultimately the patient 
may be unable to walk without the assistance of two canes. This gait is 
very characteristic, and unlike that seen in any other disease. The inco- 
ordination is not only in walking, but in the performance of other move- 
ments. If the patient is asked, when in the recumbent posture, to touch 
the knee with one foot, the irregularity in the movement is very evident. 
Incoordination of the arms is less common, but usually develops in some 
grade. It may in rare instances exist before the incoordination of the legs. 
It may be tested by asking the patient to close his eyes and to touch the tip 
of the nose or the tip of the ear with the finger, or with the arms thrust out 
to bring the tips of the fingers together. The incoordination may early be 
noticed by a difficulty which the patient experiences in buttoning his collar 
or in performing one of the ordinary routine acts of dressing. 

One of the most striking features of the disease is that with marked 



924 



DISEASES OF THE NERVOUS SYSTEM. 



incoordination there is no loss of muscular power. The grip of the hands 
may be strong and firm, the power of the legs, tested by trying to flex them, 
may be unimpaired, and their nutrition, except toward the close, may be 
unaffected. 

There is a remarkable muscular relaxation which enables the joints to 
be placed in positions of hyperextension and hyperflexion. It gives some- 
times a marked backward curve to the legs. Frankel, who calls the condi- 
tion hypotonia, says it may be an early symptom. 

Sensory Symptoms. — The lightning pains may persist. They vary 
greatly in different cases. Some patients are rendered miserable by the 
frequent occurrence of the attacks; others escape altogether. In addition, 
common symptoms are tingling, pins and needles, particularly in the feet, 
and areas of hyperesthesia or of anaesthesia. The patient may complain of 
a change in the sensation in the soles of the feet, as if cotton was inter- 
posed between the floor and the skin. Sensory disturbances occur less 
frequently in the hands. Objective sensory disturbances can usually be 
demonstrated, and indeed almost every variety of sensory disturbance has 
been described. They have been carefully studied in this country by Knapp 
and by Patrick, and in Europe by many observers. Bands about the chest 
of a moderate grade of anaesthesia are not uncommon; they are apt to 
follow the distribution of spinal segments. The most marked disturbances 
are usually found on the legs. Retardation of the sense of pain is common, 
and a pin-prick on the foot is first felt as a simple tactile impression, and 
the sense of pain is not perceived for a second or two or may be delayed for 
as much as ten seconds. The pain felt may persist. A curious phenomenon 
is the loss of the power of localizing the pain. For instance, if the patient 
is pricked on one limb he may say that he feels it on the other (allocheiria), 
or a pin-prick on the foot may be felt on both feet. The muscular sense 
which is usually affected early, becomes much impaired and the patient 
no longer recognizes the position in which his limbs are placed. This may 
be present in the pre-ataxic stage. 

Reflexes. — As mentioned, the loss of the knee-jerk is one of the earliest 
symptoms of the disease. Occasionally a case is found in which it is re- 
tained. The skin reflexes may at first be increased, but later are usually 
involved with the deep reflexes. 

Special Senses. — The eye symptoms noted above may be present, but, 
as mentioned, ataxia is rare with atrophy of the optic nerve. 

Deafness may develop, due to lesion of the auditory nerve. There may 
also be attacks of vertigo. Olfactory symptoms are rare. 

Visceral Symptoms. — Among the most remarkable sensory disturbances 
are the tabetic crises, severe paroxysms of pain referred to various viscera: 
thus laryngeal, gastric, nephric, rectal, urethral, and clitoral crises have 
been described. The most common are the gastric and laryngeal. In the 
former there are intense pains in the stomach, vomiting, and a secretion 
of hyperacid gastric juice. The attack may last for several days or even 
longer. There may be severe pain without any vomiting. The attacks are 
of variable intensity and usually require morphia. Paroxysms of rectal 
pain and tenesmus are described. They have not been common in my 



DISEASES OF THE AFFERENT OR SENSORY SYSTEM. 



925 



experience. Laryngeal crises also are rare. There may be true spasm with 
dyspnoea and noisy inspiration. In one instance at least the patient has 
died in the attack. There are also nasal crises, associated with sneezing fits. 

The sphincters are frequently involved. Early in the disease there may 
be a retardation or hesitancy in making water. Later there is retention, 
and cystitis may occur. Unless great care is taken the inflammation may 
extend to the kidneys. Constipation is extremely common. Late in the 
disease the sphincter ani is weakened. The sexual power is usually lost in 
the ataxic stage. 

Trophic Changes. — Skin rashes may develop in the course of the light- 
ning pains, such as herpes, oedema, or local sweating. Alteration in the 
nails may occur. A perforating ulcer may develop on the foot, usually 
beneath the great toe. A perforating buccal ulcer has also been described. 
Onychia may prove very troublesome. 

The arthropathies or joint lesions affect chiefly the knees. They are 
unquestionably associated with the disease itself, and are not necessarily a 
result of trauma. The condition, known as Charcot's joint, is anatomic- 
ally similar to that of chronic arthritis deformans. The effusion may be 
rapid and there may be great disintegration and destruction of the carti- 
lages and bones, leading to dislocation and deformity. Suppuration may 
occur. Spontaneous fractures may occur. Among other trophic disturb- 
ances may be mentioned atrophy of the muscles, which is usually a late 
manifestation, but may be localized and associated with neuritis. In any 
very large collection of cases many instances of atrophy are found, due either 
to involvement of the ventral horns or to peripheral neuritis. 

Cerebral Symptoms. — Hemiplegia may develop at any stage of the dis- 
ease, more commonly when it is well advanced. It may be due to haemor- 
rhagic softening in consequence of disease of the vessels or to progressive 
cortical changes. Hemianesthesia is sometimes present. Very rarely the 
hemiplegia is due to coarse syphilitic disease. 

Dementia paralytica frequently exists with tabes, and it may be ex- 
tremely difficult to determine which has been the primary affection; indeed, 
some authors believe that these two diseases are simply different localizations 
of the same morbid process. In a majority of the cases the symptoms of 
locomotor ataxia have preceded those of general paresis. In other instances 
melancholia, dementia, or paranoia develop. 

(c) Paralytic Stage. — After persisting for an indefinite number of years 
the patient gradually loses the power of walking and* becomes bedridden 
or paralyzed. In this condition he is very likely to be carried off by some 
intercurrent affection, such as pyelo-nephritis, pneumonia, or tuberculosis. 

The Course of the Disease. — A patient may remain in the pre-ataxic 
stage for an indefinite period; and the loss of knee-jerk and the gray 
atrophy of the optic nerves may be the sole indication of the true nature 
of the disease. In such cases incoordination rarely develops. In a ma- 
jority of cases the progress is slow, and after six or eight years, sometimes 
less, the ataxia is well developed. The symptoms may vary a good deal; 
thus the pains, which may have been excessive at first, often lessen. The 
disease may remain stationary for years; then exacerbations occur and it 



926 



DISEASES OF THE NERVOUS SYSTEM. 



makes rapid progress. Occasionally the process seems to be arrested. There 
are instances of what may be called acute ataxia, in which, within a 
year or even less, the incoordination is marked, and the paralytic stage 
may develop within a few months. The disease itself rarely causes death, 
and after becoming bedridden the patient may live for fifteen or twenty 
years. 

Diagnosis. — In the initial stage the combination of lightning pains 
and the absence of knee-jerk is distinctive. The association of progressive 
atrophy of the optic nerves with loss of knee-jerk is also characteristic. 
The early ocular palsies are of the greatest importance. A squint, ptosis, 
or the Argyll Eobertson pupil may be the first symptom, and may exist 
with the loss only of the knee-jerk. Loss of the knee-jerk alone, however, 
does occasionally occur in healthy individuals. A history of preceding 
syphilis lends added weight to the symptoms, and its presence or absence 
may be of the utmost importance in determining the diagnosis. If the 
possibility of syphilitic infection can be excluded, a circumstance but too 
rarely met with, only the most unequivocal combination of symptoms can 
justify the diagnosis of locomotor ataxia. 

The diseases most likely to be confounded with locomotor ataxia are: 
(1) Peripheral Neuritis. — The steppage gait of arsenical, alcoholic, or dia- 
betic paralysis is quite unlike that of locomotor ataxia. In these forms 
there is a paralysis of the feet and the leg is lifted high in order that the 
toes may clear the floor. The use of the word ataxia in this connection 
should no longer be continued. In the rare cases in which the muscle 
sense nerves are particularly affected and in which there is true ataxia, the 
absence of the lightning pains and eye symptoms and the history will suffice 
in the majority of cases to make the diagnosis clear. In diphtheritic paraly- 
sis the early loss of the knee-jerk and the associated eye symptoms may sug- 
gest tabes, but the histor}', the existence of paralysis of the throat, and 
the absence of pains render a diagnosis easy. 

(2) Ataxic Paraplegia. — Marked incoordination with spastic paralysis 
is characteristic of the condition which Gowers has termed ataxic paraplegia. 
In a majority of the cases this affection is distinguished also by the ab- 
sence of pains and of eye symptoms. 

(3) Cerebral Disease. — In diseases of the brain involving the afferent 
tracts ataxia is at times a prominent symptom. It is usually unilateral or 
limited to one limb; this, with the history and the associated symptoms, 
excludes tabes. 

(4) Cerebellar Disease. — The cerebellar incoordination has only a super- 
ficial resemblance to that of locomotor ataxia, and is more a disturbance 
of equilibrium than a true ataxia; the knee-jerk is usually present, there 
are no lightning pains, no sensory disturbances; while, on the other hand, 
there are headache, optic neuritis, and vomiting. 

(5) Some acute affections involving the dorsal columns of the cord may 
be followed by incoordination and resemble tabes very closely. In a case 
under my care, the gait was characteristic and Romberg's symptom was 
present. The knee-jerk, however, was retained and there were no ocular 
symptoms. The condition had developed within three or four months, and 



DISEASES OF THE AFFERENT OR SENSORY SYSTEM. 927 



there was a well-marked history of syphilis. Under large doses of iodide 
of potassium the ataxia and other symptoms completely disappeared. 

(6) General Paresis. — In some cases this offers a serious difficulty. In 
the first place, in general paresis, tabetic symptoms often develop; on the 
other hand, there are cases of locomotor ataxia in which, toward the end, 
there are symptoms of general paresis. Cases of unusually acute ataxia 
with mental symptoms belong, as a rule, to the former disease. The ques- 
tion will be considered under general paresis. 

(7) Visceral crises and neuralgic symptoms may lead to error, and in 
middle-aged men with severe, recurring attacks of gastralgia it is always 
well to bear in mind the possibility of tabes, and to make a careful exam- 
ination of the eyes and of the knee-jerk. 

Prognosis. — Complete recovery cannot be expected, but arrest of the 
process is not uncommon and a marked amelioration of the symptoms is 
frequent. Optic-nerve atrophy, one of the most serious events in the dis- 
ease, has this hopeful aspect — that incoordination rarely follows and the 
progress may be arrested. The optic atrophy itself is occasionally checked. 
On the whole, the prognosis in tabes is bad. The experience of such men 
as Weir Mitchell, Charcot, and Gowers is distinctly opposed to the belief 
that locomotor ataxia is ever completely cured.* No such instance has 
come under my personal observation. 

Treatment. — To arrest the progress and to relieve, if possible, the 
symptoms are the objects which the practitioner should have in view. A 
quiet, well-regulated method of life is essential. It is not well, as a rule, 
for a patient to give up his occupation so long as he is able to keep about 
and perform ordinary work. I know tabetics who have for years conducted 
large businesses, and there have been several notable instances in our pro- 
fession of men who have risen to distinction in spite of the existence of this 
disease. Excesses of all sorts, more particularly in baccho et venere, should 
be carefully avoided. A man in the pre-ataxic stage should not marry. 

Care should be taken in the diet, particularly if gastric crises have oc- 
curred. To secure arrest of the disease many remedies have been em- 
ployed. Although syphilis plays such an important role in the etiology, 
it is universally acknowledged that neither mercury nor the iodide of po- 
tassium have as a rule the slightest influence over the tabetic lesions. To 
this there is but one exception — when the syphilis is comparatively recent; 
when the symptoms develop within two years of the primary infection, 
there is then a possibility of arrest by mercury and iodide of potassium. 
However, they do not always relieve. In two cases of very rapidly pro- 
gressing tabes following syphilis this medication was of no avail. Of reme- 
dies which may be tried and are believed by some writers to retard the pro- 
gress, the following are recommended: Arsenic in full doses, nitrate of 
silver in quarter-grain doses, Calabar bean, ergot, and the preparations 
of gold. % 

The treatment by suspension introduced a few years ago has already 
been practically abandoned. Good effects certainly have followed in a IV w 



* For a study of reputed cures, see L. C. Gray, N. Y. Medical Journal, November, 1889. 



928 



DISEASES OF THE NERVOUS SYSTEM. 



cases, but it was unreasonable from the outset, either on therapeutic or 
scientific grounds, to hope that by such a measure permanent changes could 
be induced in the pathological condition. The benefits were due in great 
part to suggestion and to psychical effects. In any case it must be used 
with caution. 

For the pains, complete rest in bed, as advised by Weir Mitchell, and 
counter-irritation to the spine (either blisters or the thermo-cautery) may 
be employed. The severe spells which come on particularly after excesses 
of any kind are often promptly relieved by a hot bath or by a Turkish bath. 
A prolonged course of nitrate of silver seems in some cases to allay the 
pains and lessen the liability to the attacks. I have never seen ill effects 
from its use in spinal sclerosis. Antipyrin and antifebrin may be em- 
ployed, and occasionally do good, but their analgesic poAvers in this disease 
have been greatly overrated. Cannabis indica is sometimes useful. In 
the severe paroxysms of pain hypodermics of morphia or of cocaine must 
be used. The use of morphia should be postponed as long as possible. 
Electricity is of very little benefit. For the severe attacks of gastralgia, 
morphia is also required. The laryngeal crises are rarely dangerous. 
An application of cocaine may be made during the spasm, or a few whiffs 
of chloroform may be given, or nitrite of amyl. In all cases of tabes with 
increased arterial tension the prolonged use of nitroglycerin, given in in- 
creasing doses until the physiological effect is produced, is of great service 
in allaying the neuralgic pains and diminishing the frequency of the crises. 
Its use must be guarded when there is aortic insufficiency. The special 
indication is increased tension. The bladder symptoms demand constant 
care. When the organ cannot be perfectly emptied the catheter should be 
used, and the patient may be taught its use and how to keep it thoroughly 
sterilized. 

FrankeFs method of re-education often helps the patient to regain to a 
considerable extent the control of the voluntary movements which he has 
lost. By this method the patient is first taught, by repeated systematic 
efforts, to perform simple movements; from this he goes to more and more 
complex movements. The treatment should be directed and supervised by. 
a trained teacher, as the result depends upon the skill of the teacher quite 
as much as upon the perseverance of the patient. 

III. DISEASES OF THE EFFERENT OR MOTOR TRACT. 

A. OF THE WHOLE TRACT. 
1. Progressive (Central) Muscular Atrophy 

{Poliomyelitis Anterior Chronica ; Amyotrophic Lateral Sclerosis; Progressive Bulbar 

Paralysis). 

" 0 - 

Definition. — A disease characterized by a chronic degeneration of the 
motor tract. The whole tract is usually involved, but at times the degen- 
eration is limited to the lower segments. Associated with it is a progressive 
atrophy of the muscles, combined with more or less spastic rigidity. 



DISEASES OF THE EFFERENT OR MOTOR TRACT. 



"929 



Three affections, as a rule described apart, belong together in this 
category: (a) Progressive muscular atrophy of spinal origin; (b) amyo- 
trophic lateral sclerosis; and (c) progressive bulbar paralysis. A slow 
atrophic change in the motor neurones is the anatomical basis, and the dis- 
ease is one of the whole motor path, involving, in many cases, the cortical, 
bulbar, and spinal centres. There may be simple muscular atrophy with 
little or no spasm, or progressive wasting with marked spasm and great 
increase in the reflexes. In others, there are added symptoms of involve- 
ment of the motor nuclei in the medulla — a glosso-labio-laryngeal paralysis; 
while in others, again, with atrophy (especially of the arms), a spastic con- 
dition of the legs and bulbar phenomena, tremors develop and signs of cor- 
tical lesion. These various stages may be traced in the same case. 

For convenience, bulbar paralysis will be considered separately, and I 
shall here take up together 'progressive muscular atrophy and amyotrophic 
lateral sclerosis. 

The disease is known as the Aran-Duchenne type of progressive muscular 
atrophy and as Cruveilhier's palsy, after the French physicians who early de- 
scribed it. Luys and Lockhart Clarke first demonstrated that the cells of the 
ventral horns of the spinal cord were diseased. Charcot separated two types 
— one with simple wasting of the muscles, due, he believed, to degeneration 
confined to the ventral horns (and to this he restricted the name progressive 
muscular atrophy — type, Aran-Duchenne); the other, in which there was 
spastic paralysis of the muscles followed by atrophy. As the anatomical 
basis for this he assumed a primary degeneration of the pyramidal tracts 
and a secondary atrophy of the ventral horns. To this he gave the name 
of amyotrophic lateral sclerosis. There is but little evidence, however, to 
show that any such sharp distinction can be made between these two dis- 
eases, and Leyden and Growers regard them as identical. 

Etiology. — The cause of the disease is unknown. It is more frequent 
in males than in females. It affects adults, developing after the thirtieth 
year, though occasionally younger persons are attacked. A large majority 
of all cases of progressive muscular atrophy under twenty-five years of age 
belong to the dystrophies. Cold, wet, exposure, fright, and mental worries 
are mentioned as possible causes. Erb has lately called attention to cer- 
tain cases following injury. Hereditary influences are present in certain 
cases. The rare form which occurs in infancy usually affects several mem- 
bers of the same family. Hereditary and family influences, however, play 
but a small part in the etiology of this disease, and in this it is in contrast 
to progressive neural muscular atrophy and the dystrophies. Yet, in the 
Farr family, which I recorded some years ago, in which thirteen members 
were affected in two generations, with the exception of two,., the cases oc- 
curred or proved fatal above the age of forty, and the late onset speaks 
rather for a central affection. The spastic form may develop late in life — 
after seventy — as a senile change. 

Morbid Anatomy. — The essential anatomical change is a slow de- 
generation of the motor path, involving particularly the lower motor neu- 
rones. The upper neurones are also involved, either first, simultaneously, 
or at a later period. Associated with the degeneration in the cells of the 



930 



'DISEASES OF THE NERVOUS SYSTEM. 



ventral horns there is a degenerative atrophy of the muscles. The following 
are the important anatomical changes: (d) The gray matter of the cord 
shows the most marked alteration. The large ganglion cells of the ventral 
horns are atrophied, or, in places, have entirely disappeared, the neuroglia 
is increased, and the medullated fibres are much decreased. The fibres of 
the ventral nerve-roots passing through the white matter are wasted. (&) 
The ventral roots outside of the cord are also atrophied, (c) The muscles 
which are affected show degenerative atrophy, and the inter-muscular 
branches of the motor nerves are degenerated, (d) The degeneration of the 
gray matter is rarely confined to the cord, but extends to the medulla, where 
the nuclei of the motor cerebral nerves are found extensively wasted, (e) 
In a majority of all the cases there is sclerosis in the ventro-lateral white 
tracts, the lateral pyramidal tracts particularly are diseased, but the degener- 
ation is not confined to these tracts, and extends into the ventro-lateral 
ground bundles. The direct cerebellar and the ventro-lateral ascending 
tracts are spared. The degeneration in the pyramidal tracts extends toward 
the brain to different levels, and in several cases has been traced to the 
motor cortex, the cells of which have been found degenerated. In the 
medulla the medial longitudinal fasciculus has been found diseased. 
(/) In those cases in which no sclerosis has been found in the pyramidal 
tracts there has been a sclerosis of the ventro-lateral ground bundle (short 
tracts). 

Symptoms. — Irregular pains may precede the onset of the wasting, 
and cases may be treated for chronic rheumatism. The hands are usually 
first affected, and there is difficulty in performing delicate manipulations. 
The muscles of the ball of the thumb waste early, then the interossei and 
himbricales, leaving marked depressions between the metacarpal bones. 
Ultimately the contraction of the flexor and extensor muscles and the ex- 
treme atrophy of the thumb muscles, the interossei, and lumbricales pro- 
duces the claw-hand — main en griff e of Duchenne. The flexors of the fore- 
arm are usually involved before the extensors. In the shoulder-girdle the 
deltoid is first affected; it may waste even before the other muscles of the 
upper extremity. The trunk muscles are gradually attacked; the upper 
part of the trapezius long remains unaffected. Owing to the feebleness of 
the muscles which support it, the head tends to fall forward. The platysma 
myoides is unaffected and often hypertrophies. The arms and the trunk 
muscles may be much atrophied before the legs are attacked. The face 
muscles are attacked late. Ultimately the intercostal and abdominal mus- 
cles may be involved, the wasting proceeds to an extreme grade, and the 
patient may be actually " skin and bone," and, as " living skeletons," the 
cases are not uncommon in " museums " and " side-shows." Deformities 
and contractures result, and lordosis is almost always present. A curious 
twitching of the muscles (fibrillation) is a common symptom, and may occur 
in muscles which are not yet attacked. It is a most important symptom, 
but is not, as was formerly supposed, a characteristic feature of the disease. 
The irritability of the muscles is increased. Sensation is unimpaired, but 
the patient may complain of numbness and coldness of the alfected limbs. 
The galvanic and faradic irritability of the muscles progressively dimin- 



DISEASES OF THE EFFERENT OR MOTOR TRACT. 



931 



ishes and may become extinct, the galvanic persisting for the longer time. 
In cases of rapid wasting and paralysis there may be the reaction of degen- 
eration. The excitability of the nerve-trunks may persist after the mus- 
cles have ceased to respond. The loss of power is usually proportionate to 
the wasting. 

The foregoing description applies to the group of cases in which the 
atrophy and paralysis are flaccid — atonic, as Gowers calls it. In other cases, 
those which Charcot describes as amyotrophic lateral sclerosis, spastic paraly- 
sis precedes the wasting. This tonic atrophy first involves the arms and 
then the legs. The reflexes are greatly increased. It is one of the rare con- 
ditions in which a jaw clonus may be obtained. The most typical condition 
of spastic paraplegia may be produced. On starting to walk, the patient 
seems glued to the ground and makes ineffectual attempts to lift the toes; 
then four or five short, quick steps are taken on the toes with the body 
thrown forward; and finally he starts off, sometimes with great rapidity. 
Some of the patients can walk up and down stairs better than on the level. 
The wasting is never so extreme as in the atonic form, and the loss of 
power may be out of proportion to it. The sphincters are unaffected. 
Sexual power may be lost early. Cases are met with which correspond ac- 
curately to the clinical picture given by Charcot of amyotrophic lateral 
sclerosis. These are not 'very common, and it is much more usual to have 
a combination of the two types. A flaccid atrophic paralysis with increased 
reflexes is often met with. These differences depend upon the relative ex- 
tent of the involvement of the upper and lower motor segments and the 
time of the involvement of each. The condition may be unilateral. 

As the degeneration extends upward an important change takes place 
from the development of bulbar symptoms, which may, however, precede 
the spinal manifestations. The lips, tongue, face, pharynx, and larynx 
may be involved. The lips may be affected and articulation impaired for 
years before serious symptoms occur. In the final stage there may be 
tremor, the memory fails, and a condition of dementia may develop. 

Gowers gives the following useful classification of the varieties of this 
affection: (1) Atonic atrophy, becoming extreme; (2) muscular weakness 
with spasm, but without wasting or with only slight wasting; and (3) atonic 
atrophy, rarely extreme in degree, with exaggeration of the reflexes. These 
conditions may " coexist in every degree and combination — between uni- 
versal atonic atrophy on the one hand and universal spastic paralysis with- 
out wasting on the other." 

Diagnosis. — Progressive (central) muscular atrophy begins, as a rule, 
in adult life, without hereditary or family influences (the early infantile 
form being an exception), and usually affects first the muscles of the thumb, 
and gradually involves the interossei and lumbricales. Fibrillary contrac- 
tions are common, electrical changes occur, and the deep reflexes are usu- 
ally increased. These characteristics are usually sufficient to distinguish 
it from the other forms of muscular wasting. 

In syringo-myelia the symptoms may be very similar to those in the 
spastic form of muscular atrophy. The sensory disturbances in the former 
disease make, as a rule, the diagnosis clear, but when these are absent or 



932 



DISEASES OF THE NERVOUS SYSTEM. 



but little developed it may be very difficult or even impossible to distinguish 
the diseases. 

Treatment. — The disease is incurable. I have never seen the slight- 
est benefit from drugs or electricity. The downward progress is slow but 
certain, though in a few cases a temporary arrest may take place. With a 
history of syphilis, mercury and iodide of potassium may be tried, and 
Gowers recommends courses of arsenic and the hypodermic injection of 
strychnine. Probably the most useful means is systematic massage/ partic- 
ularly in the spastic cases. 

Bulbar Paralysis (Glosso-labio-laryngeal Paralysis). 

"When the disease affects the motor nuclei of the medulla first or early, 
it is called bulbar paralysis, but it has practically no independent existence, 
as the spinal cord is sooner or later involved. 

Symptoms. — The disease usually begins with slight defect in the 
speech, and the patient has difficulty in pronouncing the dentals and lin- 
guals. The paralysis starts in the tongue, and the superior lingual muscle 
gradually becomes atrophied, and finally the mucous membrane is thrown 
into transverse folds. In the process of wasting the fibrillary tremors are 
seen. Owing to the loss of power in the tongue, the food is with difficulty 
pushed back into the pharynx. The saliva also may be increased, and is apt 
to accumulate in the mouth. When the lips become involved the patient 
can neither whistle nor pronounce the labial consonants. The mouth looks 
large, the lips are prominent, and there is constant drooling. The food 
is masticated with difficulty. Swallowing becomes difficult, owing partly 
to the regurgitation into the nostrils, partly to the involvement of the 
pharyngeal muscles. The muscles of the vocal cords waste and the voice 
becomes feeble, but the laryngeal paralysis is rarely so extreme as that of 
the lips and tongue. 

The course of the disease is slow but progressive. Death often results 
from an aspiration pneumonia, sometimes from choking, more rarely from 
involvement of the respiratory centres. The mind usually remains clear. 
The patient may become emotional. In a majority of the cases the dis- 
ease is only part of a progressive atrophy, either simple or associated with 
a spastic condition. In the latter stage of amyotrophic lateral sclerosis 
the bulbar lesions may paralyze the lips long before the pharynx or larynx 
becomes affected. 

The diagnosis of the disease is readily made, either in the acute or 
chronic form. The involvement of the lips and tongue is usually well 
marked, while that of the palate may be long deferred. A condition has 
been described, however, which may closely simulate bulbar paralysis. 
This is the so-called pseudo-bulbar form or bulbar palsy of cerebral origin. 
Bilateral disease of the motor cortex in the lower part of the ascending 
frontal convolution, or about the knee of the internal capsule, may cause 
paralysis of the lips and tongue and pharynx, which closely simulates a 
lesion of the medulla. Sometimes the S3^mptoms appear on one side, but 
in many instances they develop suddenly on both sides. A bilateral le- 



DISEASES OF THE EFFERENT OR MOTOR TRACT. 



933 



sion has usually been found, but in several instances the disease was uni- 
lateral. 

The so-called acute bulbar paralysis may be due to (a) hemorrhagic or 
embolic softening in the pons and medulla; (b) acute inflammatory softening, 
analogous to polio-myelitis, occurring occasionally as a post-febrile affection. 
It usually comes on very suddenly, hence the term apoplectiform. The 
symptoms in this form may correspond closely to those of an advanced case 
of chronic bulbar paralysis. The sudden onset and the associated symptoms 
make the diagnosis easy. In these acute cases there may be loss of power 
in one arm, or hemiplegia, sometimes alternate hemiplegia, with paralysis 
on one side of the face and loss of power on the other side of the body. 

2. Progressive Neural Muscular Atrophy. 

This form, known also as the peroneal type, or by the names of the men 
who have described it most accurately of late — namely, Charcot, Marie, and 
Tooth — occurs either as a hereditary or as a family affection. It usually 
begins in early childhood, affecting first the muscles of the feet and the 
peroneal group; as a result of the weakening of these muscles, club-foot, 
either pes equinus or pes equino-varus occurs. In rare instances the dis- 
ease may begin in the hands, but the upper limbs, as a rule, are not affected 
for some years after the legs are attacked, and the trouble then begins in 
the small muscles of the hands. Sensory disturbances are frequently present 
and form important diagnostic features. Fibrillary contractions and twitch- 
ings also occur. The electrical reactions are altered; there is either a loss or 
a very great decrease of the excitability, which can be demonstrated not 
only in the atrophic muscles, but also in muscles and nerves which are ap- 
parently normal. 

This form of muscular atrophy seems to stand between the central form 
and the muscular dystrophies. Occurring in families and beginning in 
early life, it resembles the latter, but it is more like the former in that 
fibrillary contractions and muscular twitchings are common, that the small 
muscles of the hand are apt to be involved, and that electrical changes are 
present. In the prominence of sensory symptoms it differs from both. In 
cases of acquired double club-foot this disease should be suspected. 

3. The Muscular Dystrophies 

(Dystrophia muscularis progressiva, Erb). 

Definition. — Muscular wasting, with or without an initial hypertro- 
phy, beginning in various groups of muscles, usually progressive in char- 
acter, and dependent on primary changes in the muscles themselves. A 
marked hereditary disposition is met with in the disease. 

Etiology. — No etiological factors of any moment arc known other 
than heredity. The influence may show itself by true heredity — the dis- 
ease occurring in two or more generations — or several members of the same 
generation may be affected, showing a family tendency. Many members 
of the same family may be attacked through several generations. Males, 



934 



DISEASES OF THE NERVOUS SYSTEM. 



as a rule, are more frequently affected than females. The disease is usually 
transmitted through the mother, though she may not herself be affected. 
As many as 20 or 30 cases have been described in five generations. In Erb's 
cases 44 per cent showed no heredity. The disease usually sets in before 
puberty, but may be as late as the twentieth or twenty-fifth year, or in some 
instances even later. 

Symptoms. — The first symptom noticed is, as a rule, clumsiness in 
the movements of the child, and on examination certain muscles or groups 
of muscles seem to be enlarged, particularly those of the calves. The 
extensors of the leg, the glutei, the lumbar muscles, the deltoid, triceps 
and infraspinatus, are the next most frequently involved, and may stand 
out with great prominence. The muscles of the neck, face, and forearm 
rarely suffer. Sometimes only a portion of a muscle is involved. With this 
hypertrophy of some muscles there is wasting of others, particularly the 
lower portion of the pectorals and the latissimus dorsi. The attitude when 
standing is very characteristic. The legs are far apart, the shoulders thrown 
back, the spine is greatly curved, and the abdomen protrudes. The gait is 
waddling and awkward. In getting up from the floor the position assumed, 
so well known now through Gowers' figures, is pathognomonic. The pa- 
tient first turns over in the all-fours position and raises the trunk with 
his arms; the hands are then moved along the ground until the knees are 
reached; then with one hand upon a knee he lifts himself up, grasps the 
other knee, and gradually pushes himself into the erect posture, as it has 
been expressed, by climbing up his legs. The striking contrast between the 
feebleness of the child and the powerful-looking pseudo-hypertrophic mus- 
cles is very characteristic. The enlarged muscles may, however, be rela- 
tively very strong. 

The course of the disease is slow, but progressive. Wasting proceeds 
and finally all traces of the enlarged condition of the muscles disappear. 
At this late period distortions and contractions are common. 

The muscles of the shoulder-girdle are nearly always affected early in 
the disease, causing a symptom upon which Erb lays great stress. With 
the hands under the arms, when one endeavors to lift the patient, the 
shoulders are raised to the level of the ears, and one gets the impression 
as though the child were slipping through. These " loose shoulders " are 
very characteristic. The abnormal mobility of the shoulder-blades gives 
them a winged appearance, and makes the arms seem much longer than 
usual when they are stretched out. 

The patients complain of no sensory symptoms. The atrophic mus- 
cles do not show the reaction of degeneration except in extremely rare in- 
stances. 

Clinical Forms. — A number of different types have been described, 
depending upon the age at the onset, the muscles first affected, the occur- 
rence of hypertrophy, the prominence of heredity, etc. But Erb has shown 
that there is no sharp division between these different forms, and classes 
them all under the name of dystrophia muscularis 'progressiva. For con- 
venience of description he subdivides the disease into two large groups: 

I. Those cases which occur in childhood. 



DISEASES OF THE EFFERENT OR MOTOR TRACT. 



935 



II. The cases occurring in youth and adult life. 

The first division is subdivided into (1) the hypertrophic and (2) the 
atrophic form. 

Under the hypertrophic form, which is the pseudo-hypertrophic mus- 
cular paralysis of authors, he thinks it is useful to distinguish between 
the cases in which (a) the enlarged muscles have undergone lipomatosis — 
i. e., pseudo-hypertrophy — from those (b) in which there is a real hyper- 
trophy. 

The atrophic form also includes two subclasses: (a) Those cases in 
which the muscles of the face are involved early; this corresponds to the 
infantile form of Duchenne — the Landouzy-Dejerine type, (b) Those cases 
in which the face is not involved. 

I. Dystrophia muscularis progressiva infantum. 

1. Hypertrophic form. 

(a) With pseudo-hypertrophy. 

(b) With real hypertrophy. 

2. Atrophic form. 

(a) With primary involvement of the face (infantile form of 
Duchenne). 

(b) Without involvement of the face. 

II. Dystrophia muscularis progressiva juvenum vet adultorum (ErVs 
juvenile form). 

Morbid Anatomy. — According to Erb, the disease consists in a 
change in the muscles themselves. At first the muscle-fibres hypertrophy, 
and become round; the nuclei increase, and the muscle-fibres may become 
fissured. At the same time there is a slight increase in the connective tissue. 
Sooner or later the muscle-fibres begin to atrophy, and the nuclei become 
greatly increased. Vacuoles and fissures appear, and the fibres finally be- 
come completely atrophic, the connective tissue becoming markedly in- 
creased. Fat may be deposited in the connective tissue to such an extent as 
to cause hypertrophic lipomatosis — pseudo-hypertrophy. The different 
stages of these changes may be found in a single muscle at the same time. 

The nervous system has very generally been found to be without 
demonstrable lesions, but in certain cases changes in the cells of the ventral 
horn have been described. 

Diagnosis. — The muscular dystrophies can usually be readily distin- 
guished from the other forms of muscular atrophy. 

(a) In the cerebral atrophy loss of power usually precedes the atrophy, 
which is either of a monoplegic or hemiplegic type. 

(b) From progressive (central) muscular atrophy the distinctions are 
clearly marked. This form begins in the small muscles of the hand, a situ- 
ation rarely if ever, affected by the dystrophies, which involve first those 
of the calves, the trunk, the face, or the shoulder-girdle. Tn the central 
atrophy the reaction of degeneration is present and fibrillary twitchings 
occur in both the atrophied and non-atrophied muscles. In many cases, in 
addition to the wasting in the arms, there is a spastic condition in the legs 
and increase in the reflexes. The central atrophies come on late in life; 
the dystrophies develop, as a rule, early. In the progressive muscular dys- 



936 DISEASES OF THE NERVOUS SYSTEM. 

trophies heredity plays an important role, which in the central form is quite 
subsidiary. In the rare cases of early infantile spinal muscular atrophy 
occurring in families the symptoms are so characteristic of a central disease 
that the diagnosis presents no difficulty. 

(c) In the neuritic muscular atrophies, whether due to lead or to trauma, 
the general characters and the mode of onset are distinctive. In the cases 
of multiple neuritis seen for the first time at a period when the wasting is 
marked there is often difficulty, but the absence of family history and the 
distribution are important features. Moreover, the paralysis is out of pro- 
portion to the atrophy. Sensory symptoms may be present, and in the cases 
in which the legs are chiefly involved there is usually the steppage gait so 
characteristic of peripheral neuritis. 

(d) Progressive neural muscular atrophy. Here heredity is also a factor, 
and the disease usually begins in early life, but the distribution of atrophy 
and paralysis, which in this affection is at first confined to the periphery 
of the extremities, helps to distinguish it from the dystrophies; while the 
occurrence of sensory symptoms, fibrillary contractions, and the marked 
decrease in the electrical excitability usually make the distinction clear. 

The outlook in the primary muscular dystrophies is bad. The wasting 
progresses uniformly, uninfluenced by treatment. Erb holds that by elec- 
tricity and massage the progress is occasionally arrested. The general health 
should be carefully looked after, moderate exercise allowed, frictions with 
oil applied to the muscles, and when the patient becomes bedfast, as is in- 
evitable sooner or later, care should be taken to prevent contractures in 
awkward positions. 

The three forms of progressive muscular wasting — progressive (central) 
muscular atrophy, progressive neural muscular atrophy, and the muscular 
dystrophies — have been considered as distinct diseases, but certain recent 
writings make it probable that the distinction may not be so sharp as we 
believe. Certain cases occur which seem not to belong to any one of the 
forms but to stand between them. The changes in the muscles which were 
thought to be characteristic of the dystrophies have been found in the 
other forms. The central form occurs as a family disease in infancy, and 
the nervous system has been found diseased in trie dystrophies. 

The whole question is in a chaotic state, and it is at present better to 
keep to the old divisions. Even if it should turn out to be true, as Striimpell 
suggests, that all the forms depend upon a congenital tendency of the 
motor system to degenerate, they represent well-defined clinical types, into 
which the cases can, as a rule, be grouped without difficulty, while corre- 
sponding to each there is a fairly well-determined anatomical basis. 

B. SYSTEM DISEASES OF THE UPPER MOTOR SEGMENT. 

The question of an uncomplicated primary degeneration of the upper 
motor neurones has not been decided. Cases with a clinical picture corre- 
sponding to this lesion are not uncommon, and they may persist for a long 
time without change. Unfortunately the cases which have come to autopsy 
have shown various conditions. In only two or three has the disease been 



DISEASES OF THE EFFERENT OR MOTOR TRACT. 



937 



so nearly confined to the pyramidal tract that they can be used as an argu- 
ment for the independence of this condition. The cases of Minkowski, 
Dreschfeld, and Striimpell are not absolutely conclusive, as they are not 
quite pure, although they go far to prove that a degeneration in the pyram- 
idal tract may be uncomplicated, at least for a long time. The same 
may be said for the group of cases described by Bernhardt and Striimpell 
under the name hereditary spastic spinal paralysis, in which the extensive 
systemic degeneration of the pyramidal tracts is combined with slight de- 
generation in other tracts of the cord. 

X. Spastic Paralysis of Adults 

(Tabes dorsalis spasmodique; Primary Lateral Sclerosis). 

Definition. — A gradual loss of power with spasm of the muscles of the 
body, the lower extremities being first and most affected, unaccompanied 
by muscular atrophy, sensory disturbance, or other symptoms. The patho- 
logical anatomy is undetermined, but a systemic degeneration of the pyram- 
idal tracts is assumed. 

Symptoms. — The general symptoms of spastic paraplegia in adults are 
very distinctive. The patient complains of feeling tired, of stiffness in the 
legs, and perhaps of pains of a dull aching character in the back or in the 
calves. There may be no definite loss of power, even when the spastic con- 
dition is well established. In other instances there is definite weakness. The 
stiffness is felt most in the morning. In a well-developed case the gait is 
most characteristic. The legs are moved stiffly and with hesitation, the 
toes drag and catch against the ground, and, in extreme cases, when the 
ball of the foot rests upon the ground a distinct clonus develops. The 
legs are kept close together, the knees touch, and in certain cases the ad- 
ductor spasm may cause cross-legged progression. On examination, the legs 
may at first appear tolerably supple, perhaps flexed and extended readily. 
In other cases the rigidity is marked, particularly when the limbs are ex- 
tended. The spasm of the adductors of the thigh may be so extreme that 
the legs are separated with the greatest difficulty. In cases of this extreme 
rigidity the patient usually loses the power of walking. The nutrition is 
well maintained, the muscles may be hypertrophied. The reflexes are 
greatly increased. The slightest touch upon the patellar tendon produces 
an active knee-jerk. The rectus clonus and the ankle clonus are easily ob- 
tained. In some instances the slightest touch may throw the legs into vio- 
lent clonic spasm, the condition to which Brown-Sequard gave the name of 
spinal epilepsy. The superficial reflexes are also increased. The arms may 
be unaffected for years, but occasionally they become weak and stiff at the 
same time as the legs. This was the case in a colored boy who was in my 
wards for several years. He presented a degree of general spastic rigidity 
that I have never seen equalled. The disease had begun after puberty, 
developed gradually, and remained quite stationary for more than a year 
before he left the wards. There were no other symptoms. 

The course of the disease is progressively downward. Years may elapse 
before the patient is bedridden. Involvement of the sphincters, as a rule, 
59 



938 



DISEASES OF THE NERVOUS SYSTEM. 



is late; occasionally,, however, it is early. The sensory symptoms rarely 
progress, and the patients may retain their general nutrition and enjoy ex- 
cellent health. Ocular symptoms are rare. 

The diagnosis, so far as the clinical picture is concerned, is readily made, 
bui; v it i s often very difficult to determine accurately the nature of the under- 
lying pathological condition. A history of syphilis is' present in many of 
the cases. Cases which have run a fairly typical clinical course upon com- 
ing to autopsy have been found to have been due to very different condi- 
tions — transverse myelitis, multiple sclerosis, cerebral tumor, etc. General 
paralysis of the insane may begin with symptoms of spastic paraplegia, and 
Westphal believed that it was only in relation to this disease that a primary 
sclerosis of the pyramidal tracts ever occurred. In any case the diagnosis 
of primary systemic degeneration of the pyramidal tract is, to say the least, 
doubtful. 

2. Spastic Paralysis of Infants — Spastic Diplegia — Birth Palsies 

(Paraplegia cerebralis spastica (Heine); Little's Disease). 

In this condition there is a paralysis with spasm of all extremities, dating 
from or shortly succeeding birth, more rarely following the fevers or an 
attack of convulsions. The legs are usually more involved than the arms; 
there is no wasting, no disturbance of sensation. The reflexes are increased. 
The mental condition is usually much disturbed. The patients are often 
imbeciles or idiots, helpless in mind and body. Ataxic and athetoid move- 
ments of the most exaggerated kind may occur. 

While a limited number only of cases of infantile hemiplegia are con- 
genital, on the other hand, in spastic diplegia and paraplegia a large pro- 
portion of the cases results from injury at birth. The arms may be so 
slightly affected as to make it difficult to determine whether it is a case of 
diplegia or paraplegia. The disease usually dates from birth, and a ma- 
jority of the children are born in first labors or are forceps cases, and are 
at birth asphyxiated blue babies. Ross suggests that in feet presentations 
there may be laceration or tearing of the cerebro-spinal membranes. Pre- 
mature birth is also given as a cause. 

Morbid Anatomy. — The birth palsies which ultimately induce the 
spastic diplegias or paraplegias are most frequently the result of meningeal 
haemorrhage. The importance of this condition has been shown by the 
studies of Litzmann and Sarah J. McNutt. The bleeding may come from 
the veins, or, as in one case which I saw with Hirst, from the longitudinal 
sinus. The haemorrhage has in many cases been thickest over the motor 
areas, and it seems probable that the sclerosis found in these cases may re- 
sult from compression by the blood-clot. In other instances the condition 
may be due to a foetal meningo-encephalitis. In 16 autopsies collected in 
the literature, in which the patients died at ages varying from two to thirty, 
the anatomical condition was either a diffuse atrophy, which was most com- 
mon, or porencephalus. From the fact that certain of the cases are born 
prematurely, before the pyramidal tracts are developed, it has been as- 
sumed by some that a non-development of these tracts is the cause of the 



DISEASES OF THE EFFERENT OR MOTOR TRACT. 



939 



disease. This hypothesis has been urged by Marie, who limits the name 
spastic paraplegia to that group of the infantile cases in which there is no 
evidence of involvement of the brain — intellectual disturbances, epilepsy, 
etc., and it is in these cases that he believes the pyramidal tract has re- 
mained undeveloped. 

Symptoms. — At first nothing abnormal may be noticed about the 
child. In some instances there have been early and frequent convulsions; 
then at the age when the child should begin to walk it is noticed that the 
limbs are not used readily, and on examination a stiffness of the legs and 
arms is found. Even at the age of two the child may not be able to sit 
up, and often the head is not well supported by the neck muscles. The 
rigidity, as a rule, is more marked in the legs, and there is adductor spasm. 
When supported on the feet, the child either rests on its toes and the inner 
surface of the feet, with the knees close together, or the legs may be crossed. 
The stiffness of the upper limbs varies. It may be scarcely noticeable or 
the rigidity may be as marked as in the legs. When the spastic condition 
affects the arms as well as the legs, we speak of the condition as diplegia; 
when the legs alone are involved, as paraplegia. There seems to be no suf- 
ficient reason for considering them separately. Constant irregular move- 
ments of the arms are not uncommon. The child has great difficulty in 
grasping an object. The spasm and weakness may be more evident on one 
side than the other. The mental condition is, as a rule, defective and con- 
vulsive seizures are common. 

Associated with the spastic paralysis are two allied conditions of con- 
siderable interest, characterized by spasm and disordered movements. A 
child with spastic diplegia may present, in an unusual degree, irregular 
movements of the muscles. In attempting to grasp an object the fingers 
may be thrown out in a stiff, spasmodic, irregular manner, or there may be 
constant irregular movements of the shoulders, arms, and hands, with 
slight incoordination of the head. Cases of this description have been de- 
scribed as chorea spastica, and they may be difficult to separate from mul- 
tiple sclerosis and from Friedreich's ataxia. 

A still more remarkable condition is that of bilateral athetosis, in which 
there is a combination of spasm more or less marked with the most extraor- 
dinary bizarre movements of the muscles. The condition, as a rule, dates 
from infancy. The patient may not be able to walk. The head is turned 
from side to side; there are continual irregular movements of the face mus- 
cles, and the mouth is drawn and greatly distorted. The extremities are 
more or less rigid, particularly in extension. On the slightest attempt to 
move, often spontaneously, there are extraordinary movements of the. arms 
and legs, particularly of the arms, somewhat like though much more exag- 
gerated than athetosis. The patients are often unable to help themselves 
on account of these movements. The reflexes are increased. The mental 
condition is variable. The patient may be idiotic, but in 3 of the 6 cases 
which I have seen the patients were intelligent. Massalongo, who has care- 
fully studied this condition, describes 3 cases in one family. I have col- 
lected 53 cases from the literature, 33 of which occurred in males and 20 
in females. 



940 



DISEASES OF THE NERVOUS SYSTEM. 



3. Hereditary Spastic Paraplegia 
{Hereditary Spastic Spinal Paralysis ; Family form of Spastic Spinal Paralysis). 

Much interest has been aroused in this type, cases of which have been 
described by Gee, Striimpell, Bernhardt, Latimer, Newmark, Erb, Tooth, 
Sachs, and others. Apparently we have to distinguish in this form two 
groups of cases. In one the disease develops in infancy or childhood, and 
the cases have all the characters of a paraplegia spastica cerebralis. In these 
cases, however, the symptoms pointing to disease of the brain, mental dis- 
turbances, epilepsy, etc., may be entirely wanting, and it was in relation to 
them that Erb made the suggestion that possibly too much stress had been 
laid upon the cerebral disease. He thought that a systemic degeneration 
of the lower part of the pyramidal tract accounted for the symptoms. The 
cases of amaurotic family idiocy described by Sachs, Peterson, Hirsch, and 
others do not belong here, although in them there is also a sclerosis of the 
pyramidal tract. 

In the other group of cases, described by Bernhardt and Striimpell, the 
disease develops later, usually between twenty and thirty. The progress 
is very- slow, extending over many years. At first there is no paralysis, only 
a spastic condition of the legs. The arms are affected later. Toward the 
end there may be a true paralysis, sensation may be affected, and the bladder 
may be slightly involved. In a fatal case of StrumpelFs there was an ex- 
tensive degeneration of the pyramidal tract and slight disease of the col- 
umns of Goll and of the direct cerebellar tract. 

Amaurotic Family Idiocy. — A remarkable form of infantile paralysis 
has been described by Sachs, Peterson, and Hirsch. The symptoms as sum- 
marized by Sachs are: 1. Psychic disturbances that appear in early life 
(first or second year) and progress to total idiocy. 2. Paresis, and ulti- 
mately complete paralysis of the extremities, which may be either flaccid 
or spastic. 3. Increased, decreased, or normal tendon reflexes. 4. Partial, 
followed by total, blindness (macular changes, with subsequent atrophy of 
the optic nerve). 5. Marasmus and death, usually before the second 
year. 6. Distinct familial type. Occasional symptoms are nystagmus, 
strabismus, hyperacusis, or impairment of hearing. The pathological 
changes are primitive type of the cerebral convolutions, macrogyria, de- 
generative changes in the large pyramidal cells, absence of the tangential 
fibres, and decrease of the fibres of the white matter. The blood-vessels 
are normal. There is also degeneration of the pyramidal columns of the 
cord. Of 27 cases collected by Sachs, 17 occurred in six families; all in 
Jews. 

4. Erb's Syphilitic Spinal Paralysis. 

Erb has described a symptom group under the term syphilitic spinal 
paralysis, to which much attention has been given. The points upon which 
he lays stress are a very gradual onset with a development finally of the 
features of a spastic paresis;' the tendon reflexes are greatly increased, but 
the muscular rigidity is slight in comparison with the exaggerated deep 
reflexes. There is rarely much pain, and the sensory disturbances are trivial, 



DISEASES OF THE EFFERENT OR MOTOR TRACT. 



941 



but there may be paresthesia and the girdle sensation. The bladder and 
rectum are usually involved, and there is sexual failure or impotence. And, 
lastly, improvement is not infrequent. A majority of instances of spastic 
paralysis of adults not the result of slow compression of the cord are asso- 
ciated with syphilis and belong to this group. 

Erb thought the lesion to be a special form of transverse myelitis, but 
perhaps it should be classed with the system diseases, under the name toxic 
spastic spinal paralysis. 

5. Secondary Spastic Paralysis. 

Following any lesion of the pyramidal tract we may have spastic paraly- 
sis; thus, in a transverse lesion of the cord, whether the result of slow com- 
pression (as in caries), chronic myelitis, the pressure of tumor, chronic 
meningo-myelitis, or multiple sclerosis, degeneration takes place in the 
pyramidal tracts, below the point of disease. The legs soon become stiff and 
rigid, and the reflexes increase. Bastian has shown that in compression para- 
plegia if the transverse lesion is complete, the limbs may be flaccid, without 
increase in the reflexes — paraplegic flasque of the French. The condition 
of the patient in these secondary forms varies very much. In chronic mye- 
litis or in multiple sclerosis he may be able to walk about, but with a char- 
acteristic spastic gait. In the compression myelitis, in fracture, or in caries, 
there may be complete loss of power with rigidity. 

It may be difficult or even impossible to distinguish these cases from 
those of primary spastic paralysis. Eeliance is to be placed upon the asso- 
ciated symptoms; when these are absent no definite diagnosis as to the cause 
of the spastic paralysis can be given. 

6. Hysterical Spastic Paraplegia. 

There is no spinal-cord disease which may be so accurately mimicked as 
spastic paraplegia. In the hysterical form there is wasting, the sensory 
symptoms are not marked, the loss of power is not complete, and there is not 
that extensor spasm so characteristic of organic disease. The reflexes are, 
as a rule, increased. The knee-jerk is present, and there may be a well- 
developed ankle clonus. Gowers calls attention to the fact that it is usually 
a spurious clonus, " due to a half -voluntary contraction in the calf muscles." 
A true clonus does occur, however, and there may be the greatest difficulty 
in determining whether or not the case is one of hysterical paraplegia. The 
hysterical contracture will be considered later. 

C. SYSTEM DISEASES OF THE LOWER MOTOR SEGMENT. 
1. Chronic Anterior Polio-myelitis 

(Progressive Muscular Atrophy — Aran-Duchenne). 

This disease has been considered as one of the types making up the 
progressive (central) muscular atrophies. In certain rare cases the process 
is confined to the lower motor segments. They, however, differ so little 



942 



DISEASES OP THE NERVOUS SYSTEM. 



clinically from many of the cases in which the pyramidal tracts are in- 
volved that it seems better to make no sharp distinction between them. 
The same may be said of chronic bulbar paralysis. 

2. Ophthalmoplegia. 

This disease is at times due to a chronic degeneration of the nuclei of 
the motor nerves of the eyeballs, and so is a system disease of the lower 
motor segment. It is treated of in connection with the other ocular palsies 
for the sake of simplicity and because all ophthalmoplegias are not due to 
nuclear disease. 

3. Acute Anteeiok Polio-myelitis 

{Atrophic Spinal Paralysis; Infantile Paralysis). 

This disease was formerly believed to be due to an acute inflammation 
of the cells of the ventral horns, depending upon a selective action of the 
poison for these cells, and would on this theory have properly been classed 
as a system disease of the lower motor neurones. Later observations indi- 
cate that the distribution of the inflammation depends upon the blood sup- 
ply, and possibly that a thrombotic or an embolic process may act as the 
exciting cause of the inflammation. Just why this process should always 
act through the arteries supplying the ventral horns has not been explained. 
In any case the disease appears to be a focal inflammation, and not a system 
disease. The symptoms are confined to the motor system, and for this 
reason it is considered here and not with the focal lesions of the spinal cord. 

Definition. — An affection occurring most commonly within the first 
three years of life, characterized by fever, loss of power in certain muscles, 
and rapid atrophy. 

Etiology. — The cause of the disease is unknown. It has been at- 
tributed to cold, to the irritation from dentition, or to overexertion. Since 
the days of Mephibosheth, parents have been inclined to attribute this form 
of paralysis to the carelessness of nurses in letting the children fall, but very 
rarely is the disease induced by traumatism, and in perhaps a majority of 
the cases the child is attacked while in full health. As Sinkler has pointed 
out, the cases are more common in the warm months. Boys are more 
liable to be affected than girls. Several instances of the occurrence of 
numerous cases together in epidemic form have been described. Medin re- 
ports from Stockholm an epidemic in which from the 9th of August to the 
23d of September 29 cases came under observation. In two instances two 
children in the same family were attacked within a few days. 

The most remarkable epidemic is that which occurred in the vicinity 
of Rutland, Vt., and which has been recorded by Caverly (New York Med- 
ical Record, 1894, ii). One hundred and nineteen cases occurred during 
the summer of 1894; 85 were under six years of age; 18 died. Additional 
small outbreaks have been recorded of late years in New York and in 
London, Ontario. 



DISEASES OF THE EFFERENT OR MOTOR TRACT. 



943 



Although most frequent in children in the second to fourth years, it 
develops occasionally in young adults, or even in middle-aged persons. 

Morbid Anatomy. — The disease is oftenest seen in either the cer- 
vical or lumbar enlargements. In very early cases, such as those de- 
scribed by David Drummond and Charlewood Turner, the lesion has been 
that of an acute hemorrhagic myelitis with degeneration and rapid de- 
struction of the large ganglion cells. The condition may be strictly con- 
fined to the ventral cornua; in some instances there is slight meningeal 
involvement. The investigations of Goldscheider, Siemerling, and others 
have demonstrated the arterial origin of the disease, which is localized 
in the parts supplied by the ventral median branch of the ventral spinal 
artery. Occasionally the changes are found in the region of distribution 
of the ventral radicular arteries. Marie thinks that the initial process is 
embolism or thrombosis of the arteries of the ventral horns, the result 
of an acute infection. In cases in which the examination is not made 
for some months or years the changes are very characteristic. The ven- 
tral cornu in the affected region is greatly atrophied and the large motor 
cells are either entirely absent or only a few remain. The affected half of 
the cord may be considerably smaller than the other. The ventro-lateral 
column may show slight sclerotic changes, chiefly in the pyramidal tract. 
The corresponding ventral nerve roots are atrophied, and the muscles are 
wasted and gradually undergo a fatty and sclerotic change. 

Symptoms. — In a majority of the cases, after slight indisposition 
and feverishness, the child is noticed to have lost the use of one limb. 
Convulsions at the outset are rare, not constant as in the acute cerebral 
palsies of children. Fever is usually present, the temperature rising to 
101°, sometimes to 103°. Pain is often complained of in the early stages. 
This may be localized in the back or between the shoulders; any pressure 
on the paralyzed limbs may be painful, causing the patient to cry out when 
he is moved in bed. The paralysis is abrupt in its onset and, as a rule, 
is not progressive, but reaches its maximum in a very short time, even 
within twenty-four hours. It is rarely generalized. The suddenness of 
onset is remarkable and suggests a primary affection of the blood-vessels, 
a view which the hemorrhagic character of the early lesion supports. The 
distribution' of the paralysis is very variable. Its irregularity and lack of 
symmetry is quite characteristic of the disease. One or both arms may be 
affected, one arm and one leg, or both legs; or it may be a crossed paralysis, 
the right leg and the left arm. In the upper extremities the paralysis is 
rarely complete and groups of muscles may be affected. As Remak has 
pointed out, there is an upper-arm and a lower-arm type of palsy. The del- 
toid, the biceps, brachialis anticus, and supinator longus may be affected 
in the former, and in the latter the extensors or flexors of the fingers and 
wrists. This distribution is due to the fact that muscles acting functionally 
together are represented near each other in the spinal cord. 

In the legs the tibialis anticus and extensor groups of muscles are more 
affected than the hamstrings and glutei. The muscles of the face are 
very rarely, the sphincters hardly ever involved. While the rule is for 
the paralysis to be abrupt and sudden, there are cases in which it comes 



944 



PISEASES OF THE NERVOUS SYSTEM. 



on slowly and takes from three to five days for its development. At first 
the affected limb looks natural, and as children between two and three 
are usually fat, very little change may be noticed for some time; but the 
atrophy proceeds rapidly, and the limb becomes flaccid and feels soft and 
flabby. Usually as early as the end of the first week the reaction of de- 
generation is present. The nerves are found to have lost their irritability. 
The muscles do not react to the induced current, but to the constant cur- 
rent they respond by a sluggish contraction, usually to a weaker current 
than is normal. The paralysis remains stationary for a time, and then 
there is gradual improvement. Complete recovery is rare, and, when the 
anatomical condition is considered, is scarcely to be expected. The large 
motor cells of the cornua, when thoroughly disintegrated, cannot be re- 
stored. In too many cases the improvement is only slight and permanent 
paralysis remains in certain groups. Sensation is unaffected; the skin re- 
flexes are absent, and the deep reflexes in the affected muscles are usu- 
ally lost. 

When the paralysis persists the wasting is extreme, the growth of the 
bones of the affected limb is arrested, or at any rate retarded, and the 
joints may be very relaxed; as, for instance, when the deltoid is affected, 
the head of the humerus is no longer kept in contact with the glenoid 
cavity. In the later stages very serious deformities are produced by the 
contracture of the muscles. 

Diagnosis. — The condition is only too evident in the majority of 
cases. There is a flaccid, flabby paralysis of one or more limbs which has 
set in abruptly. The rapid wasting, the lax state of the muscles, the 
electrical reactions, and the absence of reflexes distinguish it from the 
cerebral palsies. In multiple neuritis, a rare disease in childhood, the 
paralysis is bilaterally symmetrical, affects the muscles at the periphery of 
the limbs, and is combined with sensory symptoms. The pseudo-paresis 
of rickets is a condition to be carefully distinguished. In this the loss of 
power is in the legs, rapid atrophy is not present, certain movements are 
possible but painful. The general hyperesthesia of the skin, the charac- 
teristic changes in the bones, and the diffuse sweats are present. Disease 
of the hip or knee may produce a pseudo-paralysis which can with care be 
readily distinguished. Limp chorea may also be confused. 

Prognosis. — The outlook in any case for complete recovery is bad. 
The natural course of the disease must be borne in mind; the sudden onset, 
the rapid but not progressive loss of power, a stationary period, then marked 
improvement in certain muscle groups, and finally in many cases contrac- 
tures and deformities. There is no other disease in which the physician 
is so often subject to unjust criticism, and the friends should be told at the 
outset that in the severe and extensive paralysis complete recovery should 
not be expected. The best to be hoped for is a gradual restoration of power 
in certain muscle groups. In estimating the probable grade of permanent 
paralysis, the electrical examination is of great value. 

Treatment. — The treatment of acute infantile paralysis has a bright 
and a dark side. In a case of any extent complete recovery cannot be ex- 
pected; on the other hand, it is remarkable how much improvement may 



DISEASES OF THE EFFERENT OR MOTOR TRACT. 



945 



finally take place in a limb which is at first completely flaccid and helpless. 
The following treatment may be pursued: If seen in the febrile stage, a 
brisk laxative and a fever mixture may be given. The child should be in 
bed and the affected limb or limbs wrapped in cotton. As in the great 
majority of cases the damage is already done when the physician is called 
and the disease makes no further progress, the application of blisters and 
other forms of counter-irritation to the back is irrational and only cruel to 
the child. 

The general nutrition should be carefully maintained by feeding the 
child well, and taking it out of doors every day. As soon as the child can 
bear friction the affected part should be carefully rubbed; at first once a 
day, subsequently morning and evening. Any intelligent mother can be 
taught systematically to rub, knead, and pinch the muscles, using either 
the bare hand or, better still, sweet oil or cod-liver oil. This is worth all the 
other measures advised in the disease, and should be systematically prac- 
tised for months, or even, if necessary, a year or more. Electricity has a 
much more limited use, and cannot be compared with massage in main- 
taining the nutrition of the muscles. The faradic current should be applied 
to those muscles which respond. The essence of the treatment is in main- 
taining the nutrition of the muscles, so that in the gradual improvement 
which takes place in parts, at least, of the affected segments of the cord 
the motor impulses may have to deal with well-nourished, not atrophied 
muscle fibres. 

Of medicines, in the early stage ergot and belladonna have been warmly 
recommended, but it is unlikely that they have the slightest influence. 
Later in the disease strychnia may be used with advantage in one or two 
minim doses of the liquor strychnise, which, if it has no other effect, is a 
useful tonic. 

The most distressing cases are those which come under the notice of 
the physician six, eight, or twelve months after the onset of the paralysis, 
when one leg or one arm or both legs are flaccid and have little or no 
motion. Can nothing be done? A careful electrical test should be made 
to ascertain which muscles respond. This may not be apparent at first, 
and several applications may be necessary before any contractility is no- 
ticed. With a few lessons an intelligent mother can be taught to use the 
electricity as well as to apply the massage. If in a case in which the paraly- 
sis has lasted for six or eight months no observable improvement takes place 
in the next six months with thorough and systematic treatment, little or no 
hope can be entertained of further change. 

In the later stage care should be taken to prevent the deformities re- 
sulting from the contractions. Great benefit results from a carefully ap- 
plied apparatus. The tendon transplantation introduced by Goldthwaite 
seems to be a distinct advantage in many cases. Eulenberg has recently 
reported a case (1898) in which the pes equinus was marked; he was able 
to afford notable relief by tendon implantation. Half of the tendo- 
Achilles and a part of the tendon of the soleus were implanted upon the 
tendons of the peroneus longus et brevis, the remaining half of the tendo- 
Achilles being divided. The transference of the functions from the flexors 



946 



DISEASES OF THE NERVOUS SYSTEM. 



to the pronators was satisfactorily accomplished, and the results were sur- 
prisingly beneficial. 

4. Acute and Subacute Polio-myelitis in Adults. 

An acute polio-myelitis in adults, the exact counterpart of the disease 
in children, is recognized. A majority, however, of the cases described 
under this heading have been multiple neuritis; but the suddenness of 
onset, the rapid wasting, and the marked reaction of degeneration are 
thought by some to be distinguishing features. Multiple neuritis may, 
however, set in with rapidity; there may be great wasting and the reaction 
of degeneration is sometimes present. The time element alone may deter- 
mine the true nature. Eecovery in a case of extensive multiple paralysis 
from polio-myelitis will certainly be with loss of power in certain groups 
of muscles; whereas, in multiple neuritis the recovery, while slow, may be 
perfect. 

The subacute form, the paralysie generate spinale anterieure subaigue 
of Duchenne, is in all probability a peripheral palsy. The paralysis usually 
begins in the legs with atrophy of the muscles, then the arms are involved, 
but not the face. Sensation is, as a rule, not involved. 

5. Acute Ascending (Landky's) Pakalysis. 

Definition. — An ascending flaccid paralysis, beginning in the legs, 
rapidly extending to the trunk and arms, and finally involving the muscles 
of respiration. Sensation and electrical reactions are normal, and there 
is retention of sphincter control. 

Etiology and Pathology. — This disease occurs most commonly in 
males between the twentieth and thirtieth years. It has sometimes fol- 
lowed the specific fevers. The recent careful studies by Mills and Spiller, 
Thomas and Knapp, Bailey and Ewing, and Greene have not solved the 
problem of this remarkable disease. There are two views: first, that it is 
a peripheral neuritis (Boss, Neuwerk, Barth, and many others). Spiller 
found in a rapidly fatal case destructive changes in the peripheral nerves 
and corresponding alterations in the cell bodies of the ventral horns. He 
suggests that the toxic agent acts on the lower motor neurones as a whole, 
and that possibly the reason why no lesions were found in some of the cases 
is that the more delicate histological methods were not used. Secondly, 
that it is a functional disorder without a recognizable anatomical basis. 
Eecent negative autopsies support this view. While waiting for additional 
light, we may regard the disease as an acute poisoning of the lower motor 
neurones. 

Symptoms. — Weakness of the legs, gradually progressing, often with 
tolerable rapidity, is the first symptom. In some cases within a few hours 
the paralysis of the legs becomes complete. The muscles of the trunk are 
next affected, and within a few days, or even less in more acute cases, the 
arms are also involved. The neck muscles are next attacked, and finally 
the muscles of respiration, deglutition, and articulation. The reflexes are 



COMBINED SYSTEM DISEASES. 



947 



lost, "but the muscles neither waste nor show electrical changes. The sen- 
sory symptoms are variable; in some cases tingling, numbness, and hyper- 
esthesia have been present. In the more characteristic cases sensation is 
intact and the sphincters are uninvolved. Enlargement of the spleen has 
been noticed in several cases. The course of the disease is variable. It 
may prove fatal in less than two days. Other cases persist for a week or 
for two weeks. In a large proportion of the cases the disease is fatal. One 
patient was kept alive for 41 days by artificial respiration (C. M. Greene). 

The diagnosis is difficult, particularly from certain forms of multiple 
neuritis, and if we include in Landry's paralysis the cases in which sensa- 
tion is involved, distinction between the two affections is impossible. We 
apparently have to recognize the existence of a rapidly advancing motor 
paralysis without involvement of the sphincters, without wasting or elec- 
trical changes in the muscles, without trophic lesions, and without fever — 
features sufficient to distinguish it from either the acute central myelitis 
or the polio-myelitis anterior. It is doubtful, however, whether these 
characters always suffice to enable us to differentiate the cases of multiple 
neuritis. 

6. Myasthenia Gravis 
{Asthenic Bulbar Paralysis ; Erb-Goldflam's Symptom-complex). 

Some sixty cases are on record and have been analyzed by Harry Camp- 
bell and Edwin Bramwell (Brain, 1901). The etiology is unknown. Young 
persons are chiefly affected. The muscles innervated by the bulb are first 
affected — those of the eyes, the face, of mastication, and of the neck. All 
the voluntary muscles may become involved. After rest the power is re- 
covered. In severe cases paralysis may persist. The myasthenic reaction 
of Jolly is the rapid exhaustion of the muscles, by faradism, not by gal- 
vanism. There are marked remissions and fluctuations in the severity of 
the symptoms. The affected muscles in a few cases have atrophied. Of 
17 autopsies, in only 6 was anything abnormal found (C. and B.), and the 
significance of the changes is doubtful. 

The diagnosis is easy — from the ptosis, the facial expression, the nasal 
speech, the rapid fatigue of the muscles, the myasthenic reaction, the ab- 
sence of atrophy, tremors, etc., and the remarkable variations in the in- 
tensity of the symptoms. Of the 60 cases, 23 ended fatally. The patient 
may live many years; recovery may take place. Eest, strychnia in full 
doses, massage, alternate courses of iodide of potassium and mercury may 
be tried. 

IV. COMBINED SYSTEM DISEASES. 

When the disease is not confined within the limits of either the afferent 
or efferent systems, but affects both, it is known as a combined system disease. 
Some authors contend that the diseases usually classed under this head are 
not really system diseases, but are diffuse processes. This is the view taken 
by Leyden and Goldscheider, who limit the term system disease to loco- 
motor ataxia and progressive muscular atrophy. 



948 



DISEASES OF THE NERVOUS SYSTEM. 



In certain cases of locomotor ataxia which have run a fairly typical 
course there may be found after death, besides the anatomical picture corre- 
sponding to this disease, a moderate degeneration of the pyramidal tracts 
and of the ventral horns. In progressive muscular atrophy, on the other 
hand, there may be degeneration in the dorsal column. During life these 
secondary involvements of other systems, as they may be termed, may or 
may not be accompanied by demonstrable symptoms, and when such do 
occur they make their appearance late in the disease. 

There is another group of cases in which from the very first the symp- 
toms point to an involvement of both the afferent and efferent systems, and 
it is to these that the term primary combined system disease is usually 
limited. 

1. Ataxic Paeaplegia. 

This name is applied by Gowers to a disease characterized clinically by 
a combination of ataxia and spastic paraplegia, and anatomically by in- 
volvement of the dorsal and lateral columns. 

The disease is most common in middle-aged males. Exposure to cold 
and traumatism have been occasional antecedents. In striking contrast to 
ordinary tabes a history of syphilis is rarely to be obtained. 

The anatomical features are a sclerosis of the dorsal columns, which 
is not more marked in the lumbar region and not specially localized in 
the root zone of the cuneate fasciculi. The involvement of the lateral col- 
umns is diffuse, not always limited to the pyramidal tracts, and there may 
be an annular sclerosis. Marie believes that in many cases the distribution 
of the sclerosis is due to the arterial supply and not to a true systemic de- 
generation, the vessels involved being branches of the dorsal spinal artery. 

The symptoms are well defined. The patient complains of a tired feel- 
ing in the legs, not often of actual pain. The sensory symptoms of true 
tabes are absent. An unsteadiness in the gait gradually develops with 
progressive weakness. The reflexes are increased from the outset, and 
there may be well-developed ankle clonus. Eigidity of the legs slowly comes 
on, but it is rarely so marked as in the uncomplicated cases of lateral 
sclerosis. From the start incoordination is a well-characterized feature, 
and the difficulty of walking in the dark or swaying when the eyes are 
closed may, as in true tabes, be the first symptom to attract attention. 
In walking the patient uses a stick, keeps the eyes fixed on the ground, 
the legs far apart, but the stamping gait, with elevation and sudden descent 
of the feet, is not often seen. The incoordination may extend to the arms. 
Sensory symptoms are rare, but Gowers calls attention to a dull, aching 
pain in the sacral region. The sphincters usually become involved. Eye 
symptoms are rare. Late in the disease mental symptoms may develop, 
similar to those of general paresis. 

In well-marked cases the diagnosis is easy. The combination of marked 
incoordination with retention of the reflexes and more or less spasm are 
characteristic features. The absence of ocular and sensory symptoms is 
an important point. 



COMBINED SYSTEM DISEASES. 



949 



2. Primary Combined Sclerosis (Putnam). 

The studies of J. J. Putnam, Dana, Bastianelli, Eisien Kussell, Collier, 
and Batten have separated from among the lesions of the cord a fairly 
well defined disease, characterized anatomically by a diffuse degeneration, 
often in discrete patches. The dorsal and lateral columns are constantly 
involved, chiefly in the thoracic and cervical regions. The nerve roots and 
the gray matter show no changes. The lesions have the " appearance of a 
non-systemic primary neurone degeneration, not dependent upon antece- 
dent inflammation " (E. W. Taylor). 

Of Putnam's 50 cases, 31 were women, all but 5 above thirty years old. 
A majority of the patients were of small stature and slender frame, and 
in many there had been a general lack of vigor and a chronic pallor and 
debility; 7 presented profound anaemia. There was no luetic history. The 
relation of this group to anaemia is interesting. Pussell, Batten, and Col- 
lier make three groups: (1) cases of profound anaemia (and one may add of 
cachexia), in which during life no symptoms were present, but in which 
there were found combined scleroses of the cord post-mortem; (2) cases of 
progressive pernicious anaemia, in which spinal symptoms have occurred; 
(3) cases of chronic sclerosis of the cord, in which there occurs, as a sec- 
ondary feature, a severe anaemia. 

The symptoms are both sensory and motor. The onset is usually with 
numbness in the extremities, progressive loss of strength, and emaciation. 
Paraplegia gradually develops, before which there have been, as a rule, 
spastic symptoms with exaggerated knee-jerk. The arms are affected less 
than the legs. Mental symptoms suggestive of dementia paralytica may 
develop toward the close. 

3. Hereditary Ataxia (Friedreich's Ataxia). 

In 1861 Friedreich reported 6 cases of a form of hereditary ataxia, and 
the affection has usually gone by his name. Unfortunately, paramyoclonus 
multiplex is also called Friedreich's disease; so it is best, if his name is used 
in connection with this affection, to term it Friedreich's ataxia. It is a very 
different disease in many respects from ordinary tabes. It may or may not 
be hereditary. It is really a family disease, several brothers and sisters 
being, as a rule, affected. The 143 cases analyzed by Griffith occurred in 
71 unrelated families. In his series inheritance of the disease itself occurred 
in only 33 cases. Various influences in the parents have been noted; alco- 
holism in only 7 cases. Syphilis has rarely been present. Of the 143 cases, 
86 were males and 57 females. The disease sets in early in life, and in Grif- 
fith's series 15 occurred before the age of two years, 39 before the sixth 
year, 45 between the sixth and tenth years, 20 between the eleventh and 
fifteenth years, 18 between the sixteenth and twentieth years, and 5 be- 
tween the twentieth and twenty-fifth years. 

The morbid anatomy shows an extensive sclerosis of the dorsal and 
lateral columns of the spinal cord. The periphery, and the cerebellar tracts 
are usually involved. The observations of Dejerine and Lehille are of spe- 
cial interest, since they seem to indicate that the change in this disease is 



950 



DISEASES OF THE NEEVOUS SYSTEM. 



a neurogliar (ectodermal) sclerosis, differing entirely from the ordinary 
spinal sclerosis. According to this view, Friedreich's disease is a gliosis of 
the dorsal columns due to developmental errors; but the question is still 
unsettled. 

Symptoms. — The ataxia differs somewhat from the ordinary form. 
The incoordination begins in the legs, but the gait is peculiar. It is sway- 
ing, irregular, and more like that of a drunken man. There is not the char- 
acteristic stamping gait of the true tabes. Komberg's symptom may or 
may not be present. The ataxia of the arms occurs early and is very 
marked; the movements are almost choreiform, irregular, and somewhat 
swaying. In making any voluntary movement the action is overdone, the 
prehension is claw-like, and the fingers may be spread or overextended 
just before grasping an object. The hand frequently moves about an object 
for a moment and then suddenly pounces upon it. There are irregular, 
swaying movements, some of which are choreiform, of the head and shoul- 
ders. There is present in many cases what is known as static ataxia, that is 
to say, ataxia of quiet action. It occurs when the body is held erect or when 
a limb is extended — irregular, oscillating movements of the head and body 
or of the extended limb. 

Sensory symptoms are not usually present. The deep reflexes are lost 
early in the disease, and, next to the ataxia, this is the most constant and 
important symptom (Strumpell). The skin reflexes are usually normal, 
and the pupillary reflex to light is practically never affected. 

Nystagmus is a characteristic symptom. Atrophy of the optic nerve 
rarely occurs. A striking feature is early deformity of the feet. There 
is talipes equinus, and the patient walks on the outer edge of the feet. 
The big toe is flexed dorsally on the first phalanx. Lateral curvature of 
the spine is very common. 

Trophic lesions are rare. As the disease advances paralysis comes on 
and may ultimately be complete. Some of the patients never walk. 

Disturbance of speech is common. It is usually slow and scanning; 
the expression is often dull; the mental power is, as a rule, maintained, but 
late in the disease becomes impaired. 

The diagnosis of the disease is not difficult when several members of 
a family are affected. The onset in childhood, the curious form of inco- 
ordination, the loss of knee-kicks, the early talipes equinus, the posi- 
tion of the great toe, the scoliosis, the nystagmus, and scanning speech make 
up an unmistakable picture. The disease is often confounded with chorea, 
with the ordinary form of which it has nothing in common. With hered- 
itary chorea it has certain similarities, but usually this disease does not set 
in until after the thirtieth year. 

The affection lasts for many years and is incurable. Care should be 
taken to prevent contractures. 

Cerebellar Type. — There is a form of hereditary ataxia, described by 
Marie as cerebellar heredo-ataxia, which starts later in life, after the age of 
twenty, with disability in the legs, but the gait is less ataxic than " groggy." 
The knee-jerks are retained, and a spastic condition of the legs ultimately 
develops. There is no scoliosis, nor does club-foot develop. Sanger Brown's 



AFFECTION'S OF THE MENINGES. 



951 



cases, 25 in one family, and J. H. N"eff's, 13, appear to belong to this type. 
The cerebellum has been found atrophied in 2 cases. 

4. Progressive Interstitial Hypertrophic Neuritis of Infants. 

Under this imposing title Dejerine and Sottas described a rare and inter- 
esting affection. It is a family disease, and begins in early life. The symp- 
toms are those typical of locomotor ataxia, to which is added progressive 
muscular atrophy, with involvement of the face and a hypertrophy and 
hardening of the peripheral nerves. As the name indicates, it is an inter- 
stitial hypertrophic neuritis with secondary involvement of the dorsal col- 
umns of the cord. This disease has been associated with progressive neural 
muscular atrophy, but Dejerine has shown that it is quite distinct. 

5. Toxic Combined Sclerosis. 

Certain poisons cause changes in the lateral and dorsal columns of the 
cord that resemble those of the combined system diseases. They have been 
demonstrated in pellagra and in ergotism, and have already been described. 
In pernicious anaemia and many chronic wasting disease these scleroses 
occur, and are believed to be due to the action of poisons produced within 
the system. 



III. DIFFUSE DISEASES OF THE NEKYOUS SYSTEM. 

I. AFFECTIONS OF THE MENINGES. 

Diseases of the Dura Mater (Pachymeningitis). 

Pachymeningitis Externa.— (7^raZ— Haemorrhage often occurs as a 
result of fracture. Inflammation of the external layer of the dura is rare. 
Caries of the bone, either extension from middle-ear disease or due to 
syphilis, is the principal cause. In the syphilitic cases there may be a 
great thickening of the inner table and a large collection of pus between 
the dura and the bone. 

Occasionally the pus is infiltrated between the two layers of the dura 
mater or may extend through and cause a dura-arachnitis. 

The symptoms of external pachymeningitis are indefinite. In the syph- 
ilitic cases there may be a small sous communicating with the exterior. 
Compression symptoms may occur with or without paralysis. 

Spinal.— An acute form may occur in syphilitic affections of the bones, 
in tumors, and in aneurism. The symptoms are those of a compression of 
the corrl. A chronic form is much more common, and is a constant accom- 
paniment of tuberculous caries of the spine. The internal surface of the 
dura may be smooth, while the external is rough and covered with caseous 
masses. The entire dura may be surrounded or the process may be con- 
fined to the ventral surface. 



952 



DISEASES OF THE NERVOUS SYSTEM. 



Pachymeningitis Interna. — This occurs in three forms: (1) Pseudo- 
membranous, (2) purulent, and (3) hemorrhagic. The first two are un- 
important. Pseudo-membranous inflammation of the lining membrane of 
the dura is not usually recognized, but a most characteristic example of it 
came under my observation as a secondary process in pneumonia. Purulent 
pachymeningitis may follow an injury, but is more commonly the result 
of extension from inflammation of the pia. It is remarkable how rarely pus 
is found between the dura and arachnoid membranes. 

Hemorrhagic Pachymeningitis (Hwmatoma of the Dura Mater). 

Cerebral Form. — This remarkable condition, first described by Virchow, 
is very rare in general medical practice. During ten years no instance of it 
came under my observation at the Montreal General Hospital. On the other 
hand, in the post-mortem room of the Philadelphia Hospital, which received 
material from a large almshouse and asylum, the cases were not uncommon, 
and within three months I saw four characteristic examples, three of which 
came from the medical wards. The frequency of the condition in asylum 
work may be gathered from the fact that in 1,185 post mortems at the Gov- 
ernment Hospital for the Insane, Washington, to June 30, 1897, there were 
197 cases with " a true neo-membrane of internal pachymeningitis " (Black- 
burn). Of these cases, 45 were chronic dementia, 37 were general paresis, 
30 senile dementia, 28 chronic mania, 28 chronic melancholia, 22 chronic 
epileptic insanity, 6 acute mania, and 1 case imbecility. Forty-two of the 
cases were in persons over seventy years of age. 

It has also been found in profound anaemia and other diseases of the 
blood and of the blood-vessels, and is said to have followed certain of the 
acute fevers. Herter has called attention to the not infrequent occurrence 
of the lesion in badly nourished, cachectic children. 

The morbid anatomy is interesting. Virchow's view that the delicate 
vascular membrane precedes the haemorrhage is undoubtedly correct. Prac- 
tically we see one of three conditions in these cases: (a) Subdural vascular 
membranes, often of extreme delicacy, formed by the penetration of blood- 
vessels and granulation tissue into an inflammatory exudate (so-called " or- 
ganization " of an inflammatory exudate); (b) simple subdural haemor- 
rhage; (c) a combination of the two, vascular membrane and blood-clot. 
Certainly the vascular membrane may exist without a trace of haemorrhage 
— simply a fibrous sheet of varying thickness, permeated with large vessels, 
which may form beautiful arborescent tufts. On the other hand, there 
are instances in which the subdural haemorrhage is found alone, but it is 
possible that in some of these at least the haemorrhage may have destroyed 
all trace of the vascular membrane. In some cases a series of laminated 
clots are found, forming a layer from 3 to 5 mm. in thickness. Cysts may 
occur within this membrane. The source of the haemorrhage is probably the 
dural vessels. Huguenin and others hold that the bleeding comes from the 
vessels of the pia mater, but certainly in the early stage of the condition 
there is no evidence of this; on the other hand, the highly vascular sub- 
dural membrane may be seen covered with the thinnest possible sheeting 



AFFECTIONS OF THE MENINGES. 



953 



of clot, which, has evidently come from the dura. The subdural haemor- 
rhage is usually associated with atrophy of the convolutions, and it is held 
that this is one reason why it is so common in the insane, especially in de- 
mentia paralytica and dementia senilis; but there must be some other 
factor than atrophy, or we should meet with it in phthisis and various 
cachectic conditions in which the cerebral wasting is as common and almost 
as marked as in cases of insanity. 

The symptoms are indefinite, or there may be none at all, especially 
when the haemorrhages are small or have occurred very gradually, and the 
diagnosis cannot be made with certainty. Headache has been a prominent 
symptom in some cases, and when the condition exists on one side there 
may be hemiplegia. The most helpful symptoms for diagnosis, indicating 
that the haemorrhage in an apoplectic attack is meningeal, are (1) those 
referable to increased intracerebral pressure (slowing and irregularity of 
the pulse, vomiting, coma, contracted pupils reacting to light slowly or not 
at all) and (2) paresis and paralysis, gradually increasing in extent, accom- 
panied by symptoms which point to a cortical origin. Extensive bilateral 
disease may, however, exist without any symptoms whatever. 

Spinal Form. — The spinal 'pachymeningitis interna, described by Char- 
cot and Joffroy, involves chiefly the cervical region (P. cervicalis hyper- 
trophica). The interspace between the cord and the dura is occupied by a 
firm, concentrically arranged, fibrinous growth, which is seen to have de- 
veloped within, not outside of, the dura mater. It is a condition ana- 
tomically identical with the haemorrhagic pachymeningitis interna of the 
brain. The cord is usually compressed; the central canal may be dilated — 
hydromyelus — and there are secondary degenerations. The nerve roots are 
involved in the growth and are damaged and compressed. The extent is 
variable. It may be limited to one segment, but more commonly involves 
a considerable portion of the cervical enlargement. The disease is chronic, 
and in some cases presents a characteristic group of symptoms. There 
are intense neuralgic pains in the course of the nerves whose roots are 
involved. They are chiefly in the arms and in the cervical region, and 
vary greatly in intensity. There may be hyperaesthesia with numbness and 
tingling; atrophic changes may develop, and there may be areas of anaes- 
thesia. Gradually motor disturbances appear; the arms become weak and 
the muscles atrophied, particularly in certain groups, as the flexors of the 
hand. The extensors, on the other hand, remain intact, so that the con- 
dition of claw-hand is gradually produced. The grade of the atrophy de- 
pends much upon the extent of involvement of the cervical nerve roots, . 
and in many cases the atrophy of the muscles of the shoulders and arms 
becomes extreme. The condition is one of cervical paraplegia, with con- 
tractures, flexion of the wrist, and typical main en griffe. Usually before 
the arms are greatly atrophied there are the symptoms of what the French 
writers term the second stage — namely, involvement of the lower extremi- 
ties and the gradual production of a spastic paraplegia, which may develop 
several months after the onset of the disease, and is due to secondary changes 
in the cord. 

The disease runs a chronic course, lasting, perhaps, two or more years. 
60 



954 



DISEASES OF THE NERVOUS SYSTEM. 



In a few instances, in which symptoms pointed definitely to this condition, 
recovery has taken place. The disease is to be distinguished from amyo- 
trophic lateral sclerosis, syringomyelia, and tumors. From the first it is 
separated by the marked severity of the initial pains in the neck and arms; 
from the second by the absence of the sensory changes characteristic of 
syringomyelia. From certain tumors it is very difficult to distinguish; 
in fact, the fibrinous layers form a tumor around the cord. 

The condition known as hcematoma of the dura mater may occur at any 
part of the cord, or, in its slow, progressive form — pachymeningitis hem- 
orrhagica interna — may be limited to the cervical region and produce the 
symptoms just mentioned. It is sometimes extensive, and may coexist with 
a similar condition of the cerebral dura. Cysts may occur filled with hsem- 
orrhagic contents. 



Diseases of the Pia Mater (Acute Cerebrospinal Leptomeningitis). 

Etiology. — Under cerebro-spinal fever and tuberculosis the two most 
important forms of meningitis have been described. Other conditions with 
which meningitis is associated are: (1) The acute fevers, more particularly 
pneumonia, erysipelas, and septicemia; less frequently small-pox, typhoid 
fever, scarlet fever, measles, etc. (2) Injury or disease of the bones of the 
skull. In this group by far the most frequent cause is necrosis of the petrous 
portion of the temporal bone in chronic otitis. (3) Extension from disease 
of the nose. Meningitis has followed perforation of the skull in sounding the 
frontal sinuses, suppurative disease of these sinuses, and necroses of the 
cribriform plate. As mentioned under cerebro-spinal fever, the infection 
is thought to be possible through the nose.. (4) As a terminal infection in 
chronic nephritis, arterio-sclerosis, heart-disease, gout, and the wasting 
diseases of children. 

The following etiological table of the acute forms of meningitis may 
be useful to the student: 



r £• f *• \ $ l P piSm?c. \ Diploeoccus intracelMans. 

Meninges alone involved or in a general 



2. Pneumococcic. 



pneumococcus infection. 



Pneumococcus. 



1. Tuberculous 

f (a) Secondary to pneumonia, en- 

2. Pneumo- j docarditis, etc. 

coccic. j (b) Secondary to disease or injury 
[ of cranium or its fossae. 
f (a) Following local disease of cra- 
o p ■ J nium or a local infection elsewhere. 
■ • r y°S enic - 1 (p) Terminal infection in various 

L chronic maladies. 
4. Miseella- ( In typhoid fever, influenza, diph- 
neous acute •< theria, gonorrhoea, anthrax, actino- 
infections. ( mycosis, and other acute diseases. 



. . . . Bacillus tuberculosis. 
Pneumococcus. 



Various forms of staph- 
ylococci and streptococci. 

Typhoid bacillus, influ- 
enza bacillus, diphtheria 

[ infections. ( mycosis, and other acute diseases. ) bacillus, gonococcus, etc. 

Morbid Anatomy. — The basal or cortical meninges may be chiefly 
attacked. The degree of involvement of the spinal meninges varies. In 
the form associated with pneumonia and ulcerative endocarditis the disease 
is bilateral and usually limited to the cortex. In extension from disease of 
the ear it is often unilateral and may be accompanied with abscess or with 



AFFECTIONS OF THE MENINGES. 



955 



thrombosis of the sinuses. In the non-tuberculous form in children, in the 
meningitis of chronic Bright's disease, and in cachectic conditions the base 
is usually involved. In the cases secondary to pneumonia the effusion be- 
neath the arachnoid may be very thick and purulent, completely hiding 
the convolutions. The ventricles also may be involved, though in these 
simple forms they rarely present the distention and softening which is so 
frequent in the tuberculous meningitis. For a more detailed description 
the student is referred to the sections on cerebro-spinal fever and tubercu- 
lous meningitis. 

Symptoms. — The clinical features of meningitis have already been 
described at length in the diseases just referred to, and I shall here give a 
general summary. I have already, on several occasions, called attention to 
the fact that cortical meningitis is not to be recognized by any symptoms 
or set of symptoms from a condition which may be produced by the poison 
of many of the specific fevers. In the cases of so-called cerebral pneumonia, 
unless the base is involved and the nerves affected, the disease is unrecog- 
nizable, since identical symptoms may be produced by intense engorgement 
of the meninges. In typhoid fever, in which meningitis is very rare, the 
twitchings, spasms, and retractions of the neck are almost invariably as- 
sociated with cerebro-spinal congestion, not with meningitis. Actual men- 
ingitis does, however, occur in typhoid fever, and, as Ohlmacher's cases 
show, the typhoid bacilli may be present in the exudate. 

A knowledge of the etiology gives a very important clew. Thus, in 
middle-ear disease the development of high fever, delirium, vomiting, con- 
vulsions, and retraction of the head and neck would be extremely suggestive 
of meningitis or abscess. Headache, which may be severe and continuous, 
is the most common symptom. While the patient remains conscious this is 
usually the chief complaint, and even when semicomatose he may continue 
to groan and to place his hand on his head. In the fevers, particularly 
in pneumonia, there may be no complaint of headache. Delirium is fre- 
quently early, and is most marked when the fever is high. Convulsions 
are less common in simple than in tuberculous meningitis. They were 
not present in a single instance in the cases which I have seen in pneu- 
monia, ulcerative endocarditis, or septicaemia. In the simple meningitis 
of children they may occur. Epileptiform attacks which come and go are 
highly characteristic of direct irritation of the cortex. Eigidity and spasm 
or twitchings of the muscles are more common. Stiffness and retraction of 
the muscles of the neck are important symptoms; but they are by no means 
constant, and are most frequent when the inflammation is extensive on the 
meninges of the cervical cord. There may be trismus, gritting of the teeth, 
or spastic contraction of the abdominal muscles. Vomiting is a common 
symptom in the early stages, particularly in basilar meningitis. Constipa- 
tion is usually present. In the late stages the urine and feces may be 
passed involuntarily. Optic neuritis is rare in the meningitis of the cortex, 
but is not uncommon when the base is involved. Leube lays stress on the 
hyperesthesia of the skin and muscles, especially of the muscles of the neck 
and calves. 

Important symptoms are due to lesions of the nerves at the base. Stra- 



956 



DISEASES OF THE NERVOUS SYSTEM. 



bismus or ptosis may occur. The facial nerve may be involved, producing 
slight -paralysis, or there may be damage to the fifth nerve, producing an- 
aesthesia and, if the Gasserian ganglion is affected, trophic changes in the 
cornea. The pupils are at first contracted, subsequently dilated, and per- 
haps unequal. The reflexes in the extremities are often accentuated at the 
beginning of the disease; later they are diminished or entirely abolished. 
Herpes is common, particularly in the epidemic form. 

Fever is present, moderate in grade, rarely rising above 103°. In the 
non-tuberculous leptomeningitis of debilitated children and in Bright's 
disease there may be little or no fever. The pulse may be increased in fre- 
quency at first, though this is unusual. One of the striking features of the 
disease is the slowness of the pulse in relation to the temperature, even in 
the early stages. Subsequently it may be irregular and still slower. The 
very rapid emaciation which often occurs is doubtless to be referred to 
a disturbance of the cerebral influence upon metabolism. Kernig's sign 
has been described under cerebro-spinal fever. Lumbar puncture is ex- 
ceedingly valuable for diagnosis. Not only does this frequently prove 
indisputably the existence of an acute meningitis, but the bacteriological 
examination may decide as to the etiological factor, and thus yield a more 
rational basis for treatment. 

Treatment. — There are no remedies which in any way control the 
course o£ acute meningitis. An ice-bag should be applied to the head and, 
if the subject is young and full-blooded, general or local depletion may be 
practised. Absolute rest and quiet should be enjoined. When disease of 
the ear is present, a surgeon should be early called in consultation, and if 
there are symptoms of meningo-encephalitis which can in any way be local- 
ized trephining should be practised. An occasional saline purge will do 
more to relieve the congestion than blisters and local depletion. The warm 
baths, as recommended by Aufrecht and described under cerebro-spinal 
fever, should be given every three hours. It is possible that recovery may 
follow in the primary pneumococcus form (Netter). If counter-irritation 
is deemed essential, the thermo-cautery may be lightly applied to the back 
of the neck. Large doses of the perehloride of iron, iodide of potassium, 
and mercury are recommended by some authors. 

The application of an ice-cap, attention to the bowels and stomach, and 
keeping the fever within moderate limits by sponging, are the necessary 
measures in a disease recognized as almost invariably fatal, and in which 
the cases of recovery are extremely doubtful. Quincke's lumbar puncture 
(see page 107) may be used as a therapeutic measure. Furbringer in one 
case removed 60 cc. of cloudy fluid, in which tubercle bacilli were found. 
The headache and other cerebral symptoms disappeared, and the patient, 
a man of twenty, recovered. Wallis Ord and Waterhouse report a case 
of recovery, in a child of five years, after trephining and drainage. In a 
recent case Halsted made an unsuccessful attempt to irrigate the cerebro- 
spinal meninges in the manner suggested by Leonard Hill. 



SCLEROSES OF THE BRAIN. 



957 



The Simple Meningitis of Infants {Non-tuberculous Leptomeningitis 

Infantum). 

This form has been specially studied by Gee and Barlow, and has been 
exhaustively considered by Barlow and Lees in Allbutt's System. Of 110 
cases, 84 occurred during the first year. There are two classes, the verte- 
bral and the posterior-basic. In all cases there is distention of the lateral 
and third ventricles, generally of the fourth also, with " effusion of lymph, 
thickening of the pia-arachnoid, and matting of the parts over the pos- 
terior and central area of the base of the brain from the lower end of the 
medulla to the optic commissure " (J. W. Carr). The disease is most com- 
mon in infants under one year. Head retraction appears early and persists 
throughout, being rarely absent. It is usually much more marked than in 
tuberculous meningitis. Three forms of tonic spasm are seen — retraction 
of the head, opisthotonos, and extensor or flexor spasm of the limbs. At 
a comparatively early stage, even weeks before death, the infants pass into 
stupor or complete coma. This form is sometimes met with in older chil- 
dren. As already mentioned, the evidence is accumulating to show that 
this disease is the sporadic variety of cerebro-spinal fever. 

Chronic Leptomeningitis. — This is rarely seen apart from syphilis or 
tuberculosis, in which the meningitis is associated with the growth of the 
granulomata in the meninges and about the vessels. The symptoms in such 
cases are extremely variable, depending entirely upon the situation of the 
growth. They may closely resemble those of tumor and be associated with 
localized convulsions. The epidemic meningitis may run a very chronic 
course. The leptomeningitis infantum may be chronic. In the cases re- 
ported by Gee and Barlow the duration in some instances extended even to 
a year and a half. Quincke's meningitis serosa is considered with hydro- 
cephalus. 

II. SCLEROSES OF THE BRAIN. 

General Remarks. — The connective tissue of the central nervous 
system is of two kinds — one, the neuroglia, special and peculiar, derived 
from the ectoderm, with distinct morphological and chemical characters; 
the other, in the meninges and accompanying the blood-vessels, derived 
from the mesoderm, identical with the ordinary collagenous fibrous tissue 
of the body. Both play important parts in indurative processes in the 
brain and cord. A convenient division of the cerebro-spinal scleroses is into 
degenerative, inflammatory, and developmental forms. 

The degenerative scleroses comprise the largest and most important sub- 
division, in which provisionally the following groups may be made: (a) 
The common secondary degeneration which follows when nerve-fibres are 
cut off from their trophic centres (the severance of portions of neurones 
from the main portions containing the nuclei); (b) toxic forms, among which 
may be placed the scleroses from lead and ergot, and, most important of all, 
the sclerosis of the dorsal columns, due in such a large proportion of cases 
to the virus of syphilis. Other unknown toxic agents may possibly induce 



958 



DISEASES OF THE NERVOUS SYSTEM. 



degeneration of the nerve-fibres in certain tracts. The systemic paths in 
the cord differ apparently in their susceptibility and the dorsal columns 
appear most prone to undergo this change; (c) the sclerosis associated 
with change in the smaller arteries and capillaries, which is met with as a 
senile process in the convolutions. In all probability some of the forms of 
insular sclerosis are due to primary alterations in the blood-vessels; but 
it is not yet settled whether the lesion in these cases is a primary degen- 
eration of the nerve cells and fibres to which the sclerosis is secondan^, or 
whether the essential factor is an alteration in nutrition caused by lesions 
of the capillaries and smaller arteries. 

The inflammatory scleroses embrace a less important and less extensive 
group, comprising secondary forms which develop in consequence of irri- 
tative inflammation about tumors, foreign bodies, haemorrhages, and abscess. 
Histologically these are chiefly mesodermic (vascular) scleroses, which arise 
from the connective tissue about the blood-vessels. Possibly a similar 
change may follow the primary, acute encephalitis, which Strumpell holds 
is the initial lesion in the cortical sclerosis which is so commonly found 
post mortem in infantile hemiplegia. 

The developmental scleroses are believed to be of a purely neurogliar 
character, and embrace the new growth about the central canal in syringo- 
myelia and, according to recent French writers, the sclerosis of the dor- 
sal columns in Friedreich's ataxia. It is stated that histologically this 
form is different from the ordinary variety. It may be, too, that the diffuse 
cortical sclerosis met with as a congenital condition without thickening 
of the meninges belongs to this type. It is not improbable that many 
forms of scleroses are of a mixed character, in which both the ectodermic 
glia and mesodermic connective tissue are involved. 

Anatomically we meet with the following varieties: 

(1) Miliary sclerosis is a term which has been applied to several differ- 
ent conditions. Gowers mentions a case in which there were grayish-red 
spots at the junction of the white and gray matters, and in which the neu- 
roglia was increased. There is also a condition in which, on the surface 
of the convolutions, there are small nodular projections, varying from a 
half to five or more millimetres in diameter. Single nodules of this sort 
are not uncommon; sometimes they are abundant. So far as is known no 
symptoms are produced by them. 

(2) Diffuse sclerosis, which may involve an entire hemisphere, or a 
single lobe, in which case the term sclerose lobaire has been applied to it 
by the French. It is not an important condition in general medical prac- 
tice, but occurs most frequently in idiots and imbeciles. In extensive cor- 
tical sclerosis of one hemisphere the ventricle is usually dilated.* The 
symptoms of this condition depend upon the region affected. There may 
be a considerable extent of sclerosis without symptoms or without much 
mental impairment. In a majority of eases there is hemiplegia or diplegia 
with imbecility or idiocy. 



* In my monograph on Cerebral Palsies of Children I have given a description of the 
distribution of the sclerosis in ten specimens in the museum at the Elwyn Institution. 



SCLEROSES OF THE BRAIN. 



959 



(3) Tuberous Sclerosis. — In this remarkable form, which is also known 
as hypertrophic sclerosis, there are on the convolutions areas, projecting 
beyond the surfaces, of an opaque white color and exceedingly firm. The 
sclerosis may not disturb the symmetry of the convolution, but simply cause 
a great enlargement, increase in the density, and a change in the color. 

These three forms are not of much practical interest except in asylum 
and institution work. The last variety forms a well-characterized disease 
of considerable importance, namely: 

(4) Insular Sclerosis (Sclerose en plaques). 

Definition. — A chronic affection of the brain and cord, characterized 
by localized areas in which the nerve elements are more or less replaced by 
connective tissue. This may occur in the brain or cord alone, more com- 
monly in both. 

Etiology. — This is obscure. Kahler, Marie, and others assign great 
importance to the infectious diseases, particularly scarlet fever. It is 
found most commonly in young persons, and cases are not uncommon in 
children, in whom Pritchard states that more than 50 cases have been re- 
ported. Sachs has recently reviewed the whole subject (Jour, of Nerv. and 
Mental Diseases, 1898). 

Morbid Anatomy. — The sclerotic areas are widely distributed 
through the brain and cord, and cases limited to either part alone are almost 
unknown. The grayish-red areas are scattered indifferently through the 
white and gray matter (E. W. Taylor). The patches are most abundant 
in the neighborhood of the ventricles, and in the pons, cerebellum, basal 
ganglia, and the medulla. The cord may be only slightly involved or 
there may be irregular areas in different regions. The cervical region is 
most often the seat of nodules. The nerve-roots and the branches of the 
cauda equina are often attacked. Histologically in the sclerosed patches 
there is very marked proliferation of the neuroglia, the fibres of which are 
denser and firmer. The gradual growth destroys the medulla of the nerves, 
but the axis cylinders persist in a remarkable way. There is as a conse- 
quence relatively little secondary degeneration of nerve tracts. 

Symptoms.— The onset is slow and the disease is chronic. Feeble- 
ness of the legs with irregular pains and stiffness are among the early 
symptoms. Indeed, the clinical picture may be that of spastic paraplegia 
with great increase in the reflexes. The following are the most important 
features: 

(a) Volitional Tremor or So-called Intention Tremor. — There is no paraly- 
sis of the arms, but on attempting to pick up an object there is trembling 
or rapid oscillation. A patient may be unable to lift even a glass of water 
to the mouth. The tremor may be marked in the legs and in the head, 
which shakes as he walks. When the patient is recumbent the muscles may 
be perfectly quiet. On attempting to raise the head from the pillow, 
trembling at once comes on. (b) Scanning Speech. — The words are pro- 
nounced slowly and separately, or the individual syllables may be accentu- 
ated. This staccato or syllabic utterance is a common feature, (c) Nys- 



960 



DISEASES OF THE NERVOUS SYSTEM. 



tagmus, a rapid oscillatory movement of both eyes, constitutes an important 
symptom. 

Sensation is unaffected in a majority of the cases. Optic atrophy some- 
times occurs, but not so frequently as in tabes. The sphincters, as a rule, 
are unaffected until the last stages. Mental debility is not uncommon. 
Remarkable remissions occur in the course of the disease, in which for a 
time all the symptoms may improve. Vertigo is common, and there may 
be sudden attacks of coma, such as occur in general paresis. 

The symptoms, on the whole, are extraordinarily variable, corresponding 
to the very irregular distribution of the nodules. 

The diagnosis in well-marked cases is easy. Volitional tremor, scan- 
ning speech, and nystagmus form a characteristic symptom-group. With 
this there is usually more or less spastic weakness of the legs. Paralysis 
agitans, certain cases of general paresis, and occasionally hysteria may 
simulate the disease very closely. If the case is not seen until near the 
end the diagnosis may be impossible. Buzzard holds that of all organic 
diseases of the nervous system disseminated sclerosis in its early stages is 
that which is most commonly mistaken for hysteria. The points to be 
relied upon in the differentiation are, in order of importance, the nystag- 
mus, the bladder disturbances, and the volitional tremor. The tremor in 
hysteria is not volitional. Unilateral cases are recorded. 

Much more puzzling, however, are the instances of pseudo-sclerose en 
plaques, which have been described by Westphal. French writers regard 
them as instances of hysterical tremor. In children the condition may 
with difficulty be separated from Friedreich's ataxia. 

The prognosis is unfavorable. Ultimately, the patient, if not carried 
off by some intercurrent affection, becomes bedridden. 

Treatment. — No known treatment has any influence on the progress 
of sclerosis of the brain. Neither the iodides nor mercury have the slight- 
est effect, but a prolonged course of nitrate of silver may be tried, and ar- 
senic is recommended. 



III. CHRONIC DIFFUSE MENINGOENCEPHALITIS 

( Dementia Paralytica ; General Paresis). 

Definition. — A chronic, progressive meningoencephalitis associated 
with psychical and motor disturbances, finally leading to dementia and 
paralysis. 

Etiology. — Males are affected much more frequently than females. 
It occurs chiefly between the ages of thirty and fifty-five. Heredity is a 
factor in only a few instances. An overwhelming majority of the cases are 
in married people. Statistics show that it is more common in the lower 
classes of society, but in this country in general medical practice the dis- 
ease is certainly more common in the well-to-do classes. An important 
predisposing cause is " a life absorbed in ambitious projects with all its 
strongest mental efforts, its long-sustained anxieties, deferred hopes, and 
straining expectation " (Mickle). The habits of life so frequently seen in 



CHRONIC DIFFUSE MENINGOENCEPHALITIS. 



961 



active business men in our large cities, and well expressed by the phrase 
" burning the candle at both ends/' strongly predispose to the disease. 
The important individual factor is syphilis, which is an antecedent in 
from 70 to 90 per cent of all cases. To this disease dementia paralytica 
and tabes dorsalis are so closely related that Fournier describes them 
under the heading Les Affections Parasyphilitiques. His work, with this 
title, is full of interesting details gleaned from an enormous experience. 
He suggests that these two disorders may be not merely diverse expressions 
of one and the same morbid entity, but that they possibly may be one and 
the same disease. 

Morbid Anatomy. — Both the vascular and nerve elements are in- 
volved. The general lesions in the vascular system are inflammatory, and 
those in the nerve structures degenerative. The membranes show a dif- 
fuse chronic meningitis. The dura is often thickened and vascular. There 
is increase of fluid in the subdural space. The pia in early cases is hyper- 
trophied, (edematous, and adherent to the cortex. Later there may be no 
adhesion. Its lymph spaces are full of small cells which may block the 
channels. The vessels show changes, especially in the media. In older 
cases the inflammatory condition is not so marked. 

The brain is usually small and weighs less than normal. The convolu- 
tions are atrophied, especially in the anterior and middle lobes. In acute 
cases there may be hyperemia and swelling due to congestion and oedema. 
In advanced cases the consistence is increased. Histologically there is 
atrophy of the nerve elements and hypertrophy of the connective tissue. 
The lesions of the neurone are retrogressive. Simple atrophy may be 
found. Pigmentary and fatty degeneration are common. In certain areas 
cells disappear entirely and no nerve elements are found. Adjoining areas 
may, however, show little alteration. Changes are common in the neurog- 
lia. In advanced cases there may be great diminution in the medullated 
fibres. 

There are various views as to the nature of the changes. The vascular 
theory is that from an inflammatory process starting in the sheaths of the 
arterioles there is a diffuse parenchymatous degeneration with atrophic 
changes in the nerve cells and neuroglia. A contrary view is that the pri- 
mary degeneration is in the neurone with secondary meningoencepha- 
litis. 

The degenerative changes are not limited to the cortex, but also invade 
subcortical regions and the spinal cord. In the spinal cord changes are al- 
most constantly found, usually sclerosis of the dorsal fasciculi, either alone 
or, more commonly, with involvement of the lateral. 

Symptoms. — (a) Prodromal Stage. — This is of variable duration, and 
is characterized by a general mental state which finds expression in symp- 
toms trivial in themselves but important in connection with others. Irri- 
tability, inattention to business amounting sometimes to indifference or 
apathy, and sometimes a change in character, marked by acts which may as- 
tonish the friends and relatives, may be the first indications. There may 
be unaccountable fatigue after moderate physical or mental exertion. In- 
stead of apathy or indifference there may be an extraordinary degree of 



962 



DISEASES OF THE NERVOUS SYSTEM. 



physical and mental restlessness. The patient is continually planning and 
scheming, or may launch into extravagances and speculation of the wildest 
character. A common feature at this period is the display of an un- 
bounded egoism. He boasts of his personal attainments, his property, his 
position in life, or of his wife and children. Following these features are 
important indications of moral perversion, manifested in offences against 
decency or the law, many of which acts have about them a suspicious 
effrontery. Forgetfulness is common, and may be shown in inattention to 
business details and in the minor courtesies of life. At this period there 
may be no motor phenomena. The onset of the disease is usually insidi- 
ous, although cases are reported in which epileptiform or apoplectiform 
seizures were the first s}-mptoms. Among the early motor features are 
tremor of the tongue and lips in speaking, slowness of speech and hesi- 
tancy, inequality of the pupils, and the Argyll Eobertson pupil. 

(b) Second Stage. — This is characterized in brief by mental exaltation 
or excitement and a progress in the motor symptoms. " The intensity of 
the excitement is often extreme, acute maniacal states are frequent; in- 
cessant restlessness, obstinate sleeplessness, noisy, boisterous excitement, and 
blind, uncalculating violence especially characterize such states " (Lewis). 
It is at this stage that the delusion of grandeur becomes marked and the 
patient believes himself to be possessed of countless millions or to have 
reached the most exalted sphere possible in profession or occupation. This 
expansive delirium, as it is called, is, however, not characteristic, as was 
formerly supposed, of paralytic dementia. Besides, it does not always oc- 
cur, but in its stead there may be marked melancholia or hypochondriasis, 
or, in other instances, alternate attacks of delirium and depression. 

The facies has a peculiar stolidity, and in speaking there is marked 
tremulousness of the lips and facial muscles. The tongue is also tremu- 
lous, and may be protruded with difficulty. The speech is slow, inter- 
rupted, and blurred. Writing becomes difficult on account of unsteadi- 
ness of the hand. Letters, syllables, and words may be omitted. The sub- 
ject matter of the patient's letters gives valuable indications of the mental 
condition. In many instances the pupils are unequal, irregular, sluggish, 
sometimes large. Important symptoms in this stage are apoplectiform 
seizures and paralysis. There may be slight syncopal attacks in which the 
patient turns pale and may fall. Some of these are petit mat. In the true 
apoplectiform seizure the patient falls suddenly, becomes unconscious, the 
limbs are relaxed, the face is flushed, the breathing stertorous, the tem- 
perature increased, and death may occur. The epileptic seizures are more 
common than the apoplectiform and may occur in the disease. A definite 
aura is not uncommon. The attack usually begins on one side and may not 
spread. There may be twitchings either in the facial or brachial muscles. 
Typical Jacksonian epilepsy may occur. In a case which died recently 
under my care, these seizures were among the early symptoms and the dis- 
ease was regarded as cerebral syphilis. Paralysis, either monoplegic or 
hemiplegic, may follow these epileptic seizures, or may come on with great 
suddenness and be transient. In this stage the gait becomes impaired, the 
patient trips readily, has difficulty in going up or down stairs, and the walk 



CHRONIC DIFFUSE MENINGOENCEPHALITIS. 



963 



may be spastic or occasionally tabetic. This paresis may be progressive. 
The knee-jerk is usually increased. Bladder or rectal symptoms gradually 
develop. The patient becomes helpless, bedridden, and completely de- 
mented, and unless care is taken may suffer from bedsores. Death occurs 
from exhaustion or from some intercurrent affection. The absence of pain 
reaction on pressure upon the ulnar nerve behind the elbow (Biernackr's 
symptom) is apparently not of any special value. The spinal-cord features 
of dementia paralytica may come on with or precede the mental troubles; 
in 80 per cent of the cases they follow them. There are cases in which one 
is in doubt for a time whether the symptoms indicate tabes or dementia 
paralytica, and it is well to bear in mind that every feature of pre-ataxic 
tabes may exist in the early stage of general paresis. 

Diagnosis. — The recognition of the disease in the earliest stage is ex- 
tremely difficult, as it is often impossible to decide that the slight altera- 
tion in conduct is anything more than one of the moods or phases to which 
most men are at times subject. The following description by Folsom is 
an admirable presentation of the diagnostic characters of the early stage 
of the disease: " It should arouse suspicion if, for instance, a strong, healthy 
man, in or near the prime of life, distinctly not of the ' nervous/ neurotic, 
or neurasthenic type, shows some loss of interest in his affairs or impaired 
faculty of attending to them; if he becomes varyingly absent-minded, heed- 
less, indifferent, negligent, apathetic, inconsiderate, and, although able to 
follow his routine duties, his ability to take up new work is, no matter how 
little, diminished; if he can less well command mental attention and con- 
centration, conception, perception, reflection, judgment; if there is an un- 
wonted lack of initiative, and if exertion causes unwonted mental and 
physical fatigue; if the emotions are intensified and easily change, or are 
excited readily from trifling causes; if the sexual instinct is not reasonably 
controlled; if the finer feelings are even slightly blunted; if the person in 
question regards with a placid apathy his own acts of indifference and 
irritability and their consequences, and especially if at times he sees himself 
in his true light and suddenly fails again to do so; if any symptoms of 
cerebral vaso-motor disturbances are noticed, however vague or variable." 

There are cases of cerebral syphilis which closely simulate dementia para- 
lytica. The mode of onset is important, particularly since paralytic symp- 
toms are usually early in syphilis. The affection of the speech and tongue 
is not present. Epileptic seizures are more common and more liable to 
be cortical or Jacksonian in character. The expansive delirium is rare. 
While symptoms of general paresis are not common in connection with 
the development of gummata or definite gummatous meningitis, there are, 
on the other hand, instances of paresis which follow syphilitic infection 
so closely that an etiological connection between the two must be acknowl- 
edged. Post mortem in such cases there may be nothing more than a 
general arterio-sclerosis and diffuse meningoencephalitis, which may pre- 
sent nothing distinctive, but the lesions, nevertheless, may be caused by 
the syphilitic virus. There are certain forms of lead encephalopathy which 
resemble general paresis, and, considering the association of plumb ism with 
arterio-sclerosis, it is not unlikely that the anatomical substratum of the 



964 



DISEASES OF THE NERVOUS SYSTEM. 



disease may result from this poison. Tumor may sometimes simulate pro- 
gressive paresis, but in the former the signs of general increase of the intra- 
cranial pressure (pain in the head, choked disks, slowing of the pulse-rate, 
projectile vomiting) are usually present. 

Prognosis. — The disease rarely ends in recovery. As a rule the prog- 
ress is slowly downward and the case terminates in a few years, although 
it is occasionally prolonged ten or fifteen years. 

Treatment. — The only hope of permanent relief is in the cases follow- 
ing syphilis, which should be placed upon large doses of iodide of potas- 
sium. Careful nursing and the orderly life of an asylum are the only 
measures necessary in a great majority of the cases. For sleeplessness and 
the epileptic seizures bromides may be used. Prolonged remissions, which 
are not uncommon, are often erroneously attributed to the action of reme- 
dies. Active treatment in the early stage by wet-packs, cold to the head, 
and systematic massage have been followed by temporary improvement. 



IY. DIFFUSE AND FOCAL DISEASES OF THE SPINAL 

COED. 

I. TOPICAL DIAGNOSIS. 

We have seen that a lesion involving a definite part of the gray matter 
of the lower motor segment is accompanied by loss of the power to per- 
form certain definite movements. A disease, such as anterior polio-mye- 
litis, which is confined to the gray matter, gives as its only symptom a 
characteristic lower-segment paralysis. The muscles paralyzed reveal the 
seat of the lesion. In many instances a transverse section of the spinal 
cord is involved to a greater or less extent; if complete, there is lower-seg- 
ment paralysis at the level of the lesion. If the muscles so paralyzed are 
the same on the two sides of the body, the lesion is strictly transverse, for, 
obviously, if the cord is involved higher on one side than on the other the 
paralyzed muscles will vary accordingly. Besides the paralysis due to in- 
volvement of the lower segment, the muscles whose centres are below the 
lesion may also be paralyzed by the involvement of the upper segment in 
the pyramidal tract, and present all the characteristics of such a paralysis. 
The degree of the paralysis depends upon the intensity of the lesion of the 
pyramidal tract, and varies from a slight weakness in the flexion of the 
ankle to an absolute paralysis of all the muscles below the lesion. The 
sphincter muscles of the bladder and rectum are also often paralyzed. 

Sensory symptoms are usually less prominent, but when the spinal cord 
is much diseased there is a dulling of sensation all over the body below the 
lesion. The upper border of disturbed sensation often indicates the level 
of the disease, especially when this is in the thoracic region, where the cor- 
responding motor paralysis is not easy to demonstrate. It is to be noted 
that the anaesthesia does not reach quite to the level of the lesion; thus 
if the fifth thoracic segment be involved, the anaesthesia will include the 



TOPICAL DIAGNOSIS. 



965 



area supplied by the sixth segment, but not that supplied by the fifth. This 
is due to the overlapping of the areas. There is often a narrow zone of 
hyperesthesia above the anaesthetic region. 

When the transverse lesion is complete and the lower part of the cord is 
cut off from all influence from above, there is complete sensory and motor 
paralysis, and the deep reflexes instead of being exaggerated are lost. 

The different reflexes are dependent upon different levels of the cord 
(see Starr's table, p. 905), and their absence or presence may be important 
localizing symptoms. 

Unilateral Lesions. — The motor symptoms which follow lesions con- 
fined to one half of the cross-section of the spinal cord follow the same 
rules as those given for transverse lesions, except that they are confined to 
one side of the body — that is, they are on the same side as the lesion. 

The sensory symptoms are peculiar. On the side corresponding to the 
disease — the paralyzed side — there is anesthesia corresponding to the seg- 
ment of the cord involved; above this there is a narrow zone of hyperes- 
thesia, but below this there is no diminution in the senses of touch, pain, 
or temperature; indeed, there is often hyperesthesia. The muscular sense, 
however, is impaired. On the side opposite to the lesion there may be com- 
plete loss of the sense of touch, pain, and temperature, or it may only in- 
volve one or two of these, pain and temperature usually being associated. 

The following table, slightly modified from Gowers, illustrates the dis- 
tribution of these symptoms in a complete hemi-lesion of the cord: 



Cord. 



Zone of cutaneous hyperesthesia. 
Zone of cutaneous anaesthesia. 
Lower segment paralysis with 
atrophy. 


Lesion. 






Upper segment paralysis. 
Hyperesthesia of skin. 
Muscular sense impaired. 
Reflex action first lessened and 

then increased. 
Temperature raised. 




Muscular power normal. 
Loss of sensibility of skin. 
Muscular sense normal. 
Reflex action normal. 
Temperature same as that above 
lesion. 



It is only in exceptional cases that all these features are met with, for they 
vary with its extent and intensity. 

This combination of symptoms was first recognized by Brown-Sequard, 
after whom it has been named. It is common in syphilitic diseases of the 
cord, and may follow tumors, stab-wounds, fracture and caries of the spine, 
and it is not infrequently associated with syringomyelia and hemorrhages 
into the cord. 

The explanation of the disturbance in sensation is not satisfactory, and 
can not be until our knowledge of the paths of sensory conduction is more 
accurate. These cases have convinced 'most clinicians that in man the 
paths for touch, pain, and temperature cross in the middle line soon after 
entering the spinal cord, and proceed toward the brain in the opposite 
side, while that for muscular sense remains in the dorsal columns of the 



966 



DISEASES OF THE NERVOUS SYSTEM. 



same side. We have seen that anatomy lends some support to this view, 
and this is the explanation that is usually given. The experiments on 
animals have thrown some doubt on this view, especially those of Mott on 
monkeys, which seem to indicate that the sensory paths for the most part 
remain on the same side of the cord. 



II. AFFECTIONS OF THE BLOOD-VESSELS. 

1. Congestion. 

Apart from actual myelitis, we rarely see post mortem evidences of con- 
gestion of the spinal cord, and when we do, it is usually limited either to the 
gray matter or to a definite portion of the organ. There is necessarily, 
from the posture of the body post mortem, a greater degree of vascularity 
in the dorsal portion of the cord. The white matter is rarely found con- 
gested, even when inflamed; in fact, it is remarkable how uniformly pale 
this portion of the cord is. The gray matter often has a reddish-pink tint, 
but rarely a deep reddish hue, except when myelitis is present. If we know 
little anatomically of conditions of congestion of the cord, we know less 
clinical ly, for there are no features in any way characteristic of it. 

2. Anaemia. 

So, too, with this state. There may be extreme grades of anaemia of the 
cord without symptoms. In chlorosis and pernicious anaemia there are 
rarely symptoms pointing to the cord, and there is no reason to suppose that 
such sensations as heaviness in the limbs and tingling are especially asso- 
ciated with anaemia. 

There are, however, some very interesting facts with reference to the 
profound anaemia of the cord which follows ligature of the aorta. In ex- 
periments made in Welch's laboratory by Herter, it was found that within 
a few moments after the application of the ligature to the aorta paraplegia 
came on. Paralysis of the sphincters developed, but less rapidly. This 
condition is of interest in connection with the occasional rapid develop- 
ment of a paraplegia after profuse haemorrhage, usually from the stomach 
or uterus. It may come on at once or at the end of a week or ten days, 
and is probably due to an anatomical change in the nerve elements similar 
to that produced in Herter's experiments. The degeneration of the dorsal 
columns of the cord in pernicious anaemia has already been described. 

3. Embolism and Thrombosis. 

Blocking of the spinal arteries by emboli rarely occurs. It may be pro- 
duced experimentally, and Money found that it was associated with chorei- 
form movements. Thrombosis of the smaller vessels in connection with 
endarteritis plays an important part in many of the acute and chronic 
changes in the cord. 



AFFECTIONS OF THE BLOOD-VESSELS. 



967 



4. Endarteritis. 

It is remarkable how frequently in persons over fifty the arteries of the 
spinal cord are found sclerotic. The following forms may be met with: 
(1) A nodular peri-arteritis or endarteritis associated with syphilis and 
sometimes with gummata of the meninges; (2) an arteritis obliterans, with 
great thickening of the intima and narrowing of the lumen of the vessels, 
involving chiefly the^ medium and larger-sized arteries. Miliary aneurisms 
or aneurisms of the larger vessels are rarely found in the spinal cord. In 
the classical work of Leyden but a single instance of the latter is mentioned. 

5. HEMORRHAGE INTO THE SPINAL MEMBRANES; H^MATORRHACHIS. 

In meningeal apoplexy, as it is called, the blood may be between the 
dura mater and the spinal canal — extra-meningeal haemorrhage — or within 
the dura mater — intra-meningeal haemorrhage. 

(a) Extra-meningeal hemorrhage occurs usually as a result of trauma. 
The exudation may be extensive without compression of the cord. The 
blood comes from the large plexuses of veins which may surround the dura. 
The rupture of an aneurism into the spinal canal may produce extensive 
and rapidly fatal haemorrhage. 

(b) Intra-meningeal hcemorrhage is rather more common, but is rarely 
extensive from causes acting directly on the spinal meninges themselves. 
Scattered haemorrhages are not infrequent in the acute infectious fevers, 
and I have twice, in malignant small-pox, seen much extravasation. Bleed- 
ing occurs also in death from convulsive disorders, such as epilepsy, tetanus, 
and strychnia poisoning. The most extensive haemorrhages occur in cases 
in which the blood comes from rupture of an aneurism at the base of the 
brain, either of the basilar or vertebral, artery. In several cases of this kind 
I have found a large amount of blood in the spinal meninges. In ventricu- 
lar apoplexy the blood may pass from the fourth ventricle into the spinal 
meninges. There is a specimen in the medical museum of McGill College 
of the most extensive intraventricular haemorrhage, in which the blood 
passed into the fourth ventricle, and descended beneath the spinal arach- 
noid for a considerable distance. On the other hand, haemorrhage into 
the spinal meninges may possibly ascend into the brain. 

The symptoms in moderate grades may be slight and indefinite. In 
the non-traumatic cases the haemorrhage may either come on suddenly or 
after a day or two of uneasy sensations along the spine. As a rule, the 
onset is abrupt, with sharp pain in the back and symptoms of irritation in 
the course of the nerves. There may be muscular spasms, or paralysis may 
come on suddenly, either in the legs alone or both in the legs and arms. 
In some instances the paralysis develops more slowly and is not complete. 
There is no loss of consciousness, and there are no signs of cerebral dis- 
turbance. The clinical picture naturally varies with the site of the haemor- 
rhage. If in the lumbar region, the legs alone are involved, the reflexes may 
be abolished, and the action of the bladder and rectum is impaired. If in 
the thoracic region, there is more or less complete paraplegia, the reflexes are 



968 



DISEASES OF THE NERVOUS SYSTEM. 



usually retained, and there are signs of disturbance in the thoracic nerves, 
such as girdle sensations, pains, and sometimes eruption of herpes. In the 
cervical region the arms as well as the legs may be involved; there may 
be difficulty in breathing, stiffness of the muscles of the neck, and occa- 
sionally pupillary symptoms. 

The prognosis depends much upon the cause of the haemorrhage. Ke- 
covery may take place in the traumatic cases, and in those associated with 
the infectious diseases. 

6. Hemorrhage into the Spinal Cord (Hcematomyelia). 

It is more common in males than in females, and at the middle period 
of life. The cases have followed either cold and exposure or overexertion, 
and, most frequently of all, traumatism. It is most frequent in the lower 
cervical region, the most common site for dislocation and fracture of the 
spine. It occurs also in tetanus and convulsions. Haemorrhage into the 
cord may follow injuries of the spinal column, gun-shot wounds, etc., even 
when the cord itself has not been touched (H. Gushing). Haemorrhage may 
be associated with tumors, with syringo-myelia, or with myelitis; it is often 
difficult to determine whether the case is one of primary haemorrhage with 
myelitis, or myelitis with a secondary haemorrhage. 

The anatomical condition is very varied. The cord may be enlarged 
at the site of the haemorrhage, and occasionally the white substance may 
be lacerated and blood may escape beneath the meninges. The extravasa- 
tion is chiefly in the gray matter, and may be limited or focal, or very 
diffuse, extending a considerable distance in the cord. In a case which 
occurred at the Montreal General Hospital under Wilkins the haemorrhage 
occupied a position opposite the region of the fifth and sixth cervical nerves 
and on transverse section the cord was occupied by a dark-red clot measur- 
ing 12 by 5 mm., around which the white substance formed a thin, ragged 
wall. The clot could be traced upward as far as the second cervical, and 
downward as far as the fourth thoracic segment. 

The sudden onset of the symptoms is the most characteristic feature 
in haematomyelia. The loss of power necessarily varies with the locality 
affected. If in the cervical region, both arms and legs may be involved; 
but if in the thoracic or lumbar, there is only paraplegia. There is usually 
loss of sensation, and at first loss of reflexes. Myelitis frequently develops 
and becomes extensive, with fever and trophic changes. The condition 
may rapidly prove fatal; in other instances there is gradual recovery, often 
with partial paralysis. 

The diagnosis may be made in some instances, particularly those in 
which the onset is sudden after injury, but there is great difficulty in dif- 
ferentiating haemorrhagic myelitis from certain cases of haemorrhage into 
the spinal meninges. 



AFFECTIONS OF THE BLOOD-VESSELS. 



969 



7. Caisson Disease (Diver's Paralysis; Compressed Air Disease). 

This remarkable affection, found in divers and in workers in caissons, 
•is characterized by a paraplegia, more rarely a general palsy, which super- 
venes on returning from the compressed atmosphere to the surface. 

The disease has been carefully studied by the French writers, by Ley- 
den and Schultze in Germany, and in this country particularly by A. H. 
Smith. It has been made the subject of a special monograph by Snell. 
The pressure must be more than that of three atmospheres. The symptoms 
are especially apt to come on if the change from the high to the ordinary 
atmospheric pressure is quickly made. They may supervene immediately 
on leaving the caisson, or they may be delayed for several hours. Pains 
of the most atrocious character about the knees, elbows, or other joints, 
without swelling, as a rule, pain and swelling in the muscles, epigastric 
pain, and vomiting are the most common symptoms. Headache, giddiness, 
and paralysis are less frequent. Paraplegia occurred in 15 per cent of Dr. 
Smith's cases and in 61 per cent of the St. Louis cases. Monoplegia and 
hemiplegia are rare. In the most extreme instances the attacks resemble 
apoplexy; the patient rapidly becomes comatose and death occurs in a few 
hours. In the case of paraplegia the outlook is usually good, and the 
paralysis may pass off in a day, or may continue for several weeks or even 
for months. 

The explanation of this condition is by no means satisfactory. Several 
careful autopsies have been made. In Leyden's case death occurred on the 
fifteenth day, and in the thoracic portion of the cord there were numerous 
foci of haemorrhages and signs of an acute myelitis. In Schnitzels case 
death occurred in two and a half months, and a disseminated myelitis was 
found in the thoracic region. In both cases there were fissures, and appear- 
ances as if tissue had been lacerated. In a case examined on the third day 
(Ziegler's Beitrage, 1892) this condition of Assuring and laceration was 
found. It has been suggested that the symptoms are due to the liberation 
in the spinal cord of bubbles of nitrogen which have been absorbed by the 
blood under the high pressure, and the condition found at the autopsies 
just referred to is held to favor this view. 

Death is rare; it occurred in 12 of 76 cases at the St. Louis bridge, in 
3 of the 110 cases at the Brooklyn bridge. In the recent important work 
of the Frith of Forth bridge and the Blackwell tunnel there were no 
fatalities from this cause. 

The most successful treatment is recompression. A medical air lock 
should be provided at the works, well heated and filled with bunks, etc. 
The recompression stops the pain and relieves the symptoms. Morphia 
may be required. 



Gl 



970 



DISEASES OF THE NERVOUS SYSTEM. 



III. COMPRESSION OF THE SPINAL CORD 

(Compressio?i Myelitis). 

Definition. — Interruption of the functions of the cord by slow com- 
pression. 

Etiology. — Caries of the spine, new growths, aneurism, and parasites 
are the important causes of slow compression. Caries, or Pott's disease, as 
it is usually called, after the surgeon who first described it, is in the great 
majority of instances a tuberculous affection. In a few cases it is due to 
syphilis and occasionally to extension of disease from the pharynx. It is 
most common in early life, but may occur after middle age. It follows 
trauma in a few cases. Compression occasionally results from aneurism of 
the thoracic aorta or the abdominal aorta, in the neighborhood of the cceliac 
axis. 

' Malignant growths frequently cause a compression paraplegia. A retro- 
peritoneal sarcoma or the lymphadenomatous growths of Hodgkims disease 
may invade the vertebrae. More commonly, however, the involvement is 
secondary to»scirrhus of the breast. 

Of parasites, the echinoeoccus and the cysticercus occasionally occur in 
the spinal canal. For a masterly cousideration of the whole question, par- 
ticularly from a surgical standpoint, Kocher's monograph is all-important 
(Mitt. a. d. Grenzgebiet. der Chir. u. d. Med., 1896, Bd. i). 

Symptoms. — These may be considered as they affect the bones, the 
nerves, and the cord. 

(1) Vertebral. — In malignant diseases and in aneurism, erosion of the 
bodies may take place without producing any deformity of the spine. Fatal 
haemorrhage may follow erosion of the vertebral artery. In caries, on the 
other hand, it is the rule to find more or less deformity, amounting often 
to angular curvature. The compression is largely due to the thickening 
of the dura and the presence of caseous and inflammatory products between 
this membrane and the bone. The compression is rarely produced directly 
by the bone. Pain is a constant and, in the case of aneurism and tumor, an 
agonizing feature. In caries, the spinal processes of the affected vertebrae 
are tender on pressure, and pain follows jarring movements or twisting of 
the spine. There may be extensive tuberculous disease without much de- 
formity, particularly in the cervical region. 

(2) Nerve-root Symptoms. — These result from compression of the nerve 
roots as they pass out between the vertebras. A cervico-brachial neuralgia 
may be an early symptom. It is remarkable how frequently, even in ex- 
tensive caries, they escape and the patient does not complain of radiating 
pains in the distribution of the nerves from the affected segment. Pains 
are more common in cancer of the spine secondary to that of the breast, 
and in such cases may be agonizing. There may be acutely painful areas — 
the anoesthesia dolorosa, in regions of the skin which are anaesthetic to tac- 
tile and painful impressions. Trophic disturbances may occur, particularly 
herpes. In the cervical or lumbar regions pressure on the ventral roots 
may give rise to wasting of the muscles supplied by the affected nerves. 



COMPRESSION OF THE SPINAL CORD. 



971 



(3) Cord Symptoms. — (a) Cervical Region. — Not infrequently the caries 
is high up between the axis and the atlas or between the latter and the oc- 
cipital bone. In such instances a retropharyngeal abscess may be present, 
giving rise to difficulty in swallowing. There may be spasm of the cervical 
muscles, the head may be fixed, and movements may either be impossible 
or cause great pain. In a case of this kind in the Montreal General Hos- 
pital movement was liable to be followed by transient, instantaneous paraly- 
sis of all four extremities, owing to compression of the cord. In one of 
these attacks the patient died. 

In the lower cervical region there may be signs of interference with 
the cilio-spinal centre and dilatation of the pupils. Occasionally there is 
flushing of the face and ear of one side or unilateral sweating. Deformity 
is not so common, but healing may take place with the production of a 
callus of enormous breadth, with complete rigidity of the neck. 

(b) Thoracic Region. — The deformity is here more marked and pressure 
symptoms are more common. The time of onset of the paralysis varies 
very much. It may be an early symptom, even before the curvature is 
manifest. More commonly it is late, occurring many months after the curva- 
ture has developed. The paraplegia is slow in its development; the patient 
at first feels weak in the legs or has disturbance of sensation, numbness, 
tingling, pins and needles. The girdle sensation may be marked, or severe 
pains in- the course of the intercostal nerves. Motion is, as a rule, more 
quickly lost than sensation. Finally, there is complete interruption with 
the production of paraplegia, usually of the spastic type, with exaggeration 
of the reflexes. Bastian's symptom — abolition of the reflexes — is rarely 
met with in compression from caries. The paraplegia may persist for 
months, or even for more than a year, and recovery still be possible. 

(c) Lumbar Region. — In the lower dorsal and lumbar regions the symp- 
toms are practically the same, but the sphincter centres are involved and 
the reflexes are not exaggerated. 

Diagnosis. — Caries is by far the most frequent cause of slow com- 
pression of the cord, and when there are external signs the recognition is 
easy. There are cases in which the exudation in the spinal canal between 
the dura and the bone leads to compression before there are any signs of 
caries, and if the root symptoms are absent it may be extremely difficult 
to arrive at a diagnosis. Janeway has called attention to persistent lum- 
bago as a symptom of importance in masked Pott's disease, particularly 
after injury. Brown-Sequard's paralysis is more common in tumor and in 
injuries than in caries. Pressure on the nerve roots, too, is less frequent 
in caries than in malignant disease. The cervical form of pachymeningitis 
also produces a pressure paralysis, the symptoms of which have already been 
detailed. Pressure from secondary carcinoma is naturally suggested when 
spinal symptoms follow within a few years after an operation for cancer of 
the breast. In paraplegia following tumor of the vertebra secondary to 
cancer of the breast, and in the erosion of the spine by retroperitoneal 
growths, the suffering is most intense. The condition has been well termed 
paraplegia dolorosa. I have seen 2 cases in which the breast tumor had 
not been recognized. 



972 



DISEASES OF THE NERVOUS SYSTEM. 



Treatment. — In compression by aneurism or tumor the condition is 
hopeless. In the former the pains are often not very severe, bnt in the 
latter morphia is always necessary. On the other hand, compression by 
caries is often successfully relieved even after the paralysis has persisted 
for a long period. When caries is recognized early, rest and support to 
the spine by the various methods now used by surgeons may do much to 
prevent the onset of paraplegia. When paralysis has developed, rest with 
extension gives the best hope of recovery. It is to be remembered that 
restoration may occur after compression of the cord has lasted for many 
months, or even more than a year. Cases have been cured by rest alone; 
the extradural and inflammatory products are absorbed and the caries heals. 
The most brilliant results in these cases have been obtained by suspension, a 
method introduced by J. K. Mitchell in 1826, and pursued with remarkable 
success by his son, Weir Mitchell. During my association with the Infirmary 
for Nervous Diseases I had numerous opportunities of witnessing the really 
remarkable effects of persistent suspension, even in apparently desperate 
and protracted cases. Mitchell's conclusions are that suspension should 
be employed early in Pott's disease; that used with care it enables us slowly 
to lessen the curve; that in these cases there must be, in some form, a re- 
placement of the crumpled tissues; that unless there is great loss of power 
the use of the spine-car or chair of J. K. Mitchell enables suspension, espe- 
cially in children, to be combined with some exercise; that no case of Pott's 
disease should be considered desperate without its trial; that suspension 
has succeeded after failures of other accepted methods; that the pull prob- 
ably acts more or less directly on the cord itself, and that the gain is not 
explicable merely by obvious effects on the angular bone curve; that the 
methods of extension to be used in carious cases may be very varied, pro- 
vided only we get active extension; that the plan and the length of time 
of extension must be made to conform to the needs, endurance, and sensa- 
tion of the individual case. It may be months before there are any signs 
of improvement. In protracted cases, after suspension has been tried for 
months, laminectomy may be considered, and has in some instances been 
successful. 

The general treatment of caries is that of tuberculosis — fresh air, good 
food, cod-liver oil, and arsenic. Counter-irritation in these instances is of 
doubtful value. 

Lesions of the Cauda Equina and Conus Medullaris. 

The spinal cord extends only to the second lumbar vertebra. Injury, 
tumors, and caries at or below this level involve not the cord itself, but the 
bundle of nerves known as the cauda equina and the terminal portion of 
the cord, the conus medullaris. Much attention has been given to lesions 
of this part, The whole subject is admirably discussed in Thorburn's work. 
Fractures and dislocations are common in the lumbo-sacral region, tumors 
not infrequently involve the filaments of the cauda equina, and some of 
the nerves may be entangled in the cicatrix of a spina bifida. 

In a fracture or dislocation of the first lumbar vertebra the conus me- 



TUMORS OF THE SPINAL CORD AND ITS MEMBRANES. 973 



dullaris may be compressed with the last sacral nerves given off from it. 
In a case reported by Kirchhoff there was laceration of the conus with 
complete paralysis of the bladder and rectum, a case which is held to favor 
the view that the ano-vesical centre in man is situated in this region of the 
cord. There are several instances on record in which injury of the cauda 
equina has produced paralysis of the bladder and rectum alone, sometimes 
with a slight patch of anaesthesia in the neighborhood of the coccyx or the 
perinaeum. More commonly branches of the sacral or lumbar nerve roots 
are involved, producing an irregularly distributed motor and sensory paraly- 
sis in the legs. When the lumbar nerve roots from the second to the fifth 
are compressed, there is paralysis of the muscles of the legs, with the ex- 
ception of the flexors of the ankles, the peronsei, the long flexors of the 
toes, and the intrinsic muscles of the feet, and loss of sensation in the front, 
inner and outer part of the thighs, the inner side of the legs, and the inner 
side of the foot. The sacral roots may alone be involved. Thus in a case 
which I have reported the patient fell from a bridge and had paralysis of 
the legs and of the bladder and rectum. When seen sixteen years after the 
injury, there was slight weakness, with wasting of the left leg; there was 
complete loss of the function in the ano-vesical and genital centres, and 
anaesthesia in a strip at the back part of the thigh (in the distribution of 
the small sciatic), and of the perinaeum, scrotum, and penis. The urethra 
was also insensitive. 

Starr's table and Head's figures, given in the general introduction, will 
be found useful in determining the nerve fibres and segments involved in 
these cases of injury of the cauda equina. 



IV. TUMORS OF THE SPINAL CORD AND ITS 
MEMBRANES. 

New growths may develop in the cord or in its membranes, or may 
extend into them from the spine. The first two alone will be considered. 
Occasionally lipoma and parasites occur in the extradural space. Within 
the dura fibromata, sarcomata, and syphilitic and tuberculous growths are 
most common. In the cord itself, and attached to the pia mater, the tu- 
berculous, syphilitic, and gliomatous growths are most frequent. Of 50 
cases of tumor of the spinal cord and its envelopes, analyzed by Mills and 
Lloyd, only 3 were parasitic. Of these, 26 were some form of neoplasm, of 
which sarcomata were most common, 5 were gummatous, and 4 tubercu- 
lous. Herter has recently reported 3 cases of solitary tubercle in the cord, 
and has analyzed others from the literature. Of 24 cases in which the age 
was given, 15 occurred between the ages of fifteen and thirty-five, and 5 
before the fifth year. The tumor is most common in the dorsal and lumbar 
regions, and is usually met with in connection with tuberculous lesions else- 
where. 

The anatomical effects of tumor are very varied. Slow compression 
is usually produced by growths external to the cord, and it is remarkable 
what a high grade of compression the cord will bear without serious inter- 



974 



DISEASES OF THE NERVOUS SYSTEM. 



ference with its functions. In cases of prolonged interruption ascending 
and descending degenerations occur. Tumors developing within the cord 
may lead to syringo-myelia. And, lastly, tumors not infrequently excite 
intense myelitis. 

Symptoms. — These will naturally vary a good deal with the segment 
involved and with the degree of pressure and the extent of implication of 
the nerve roots. 

Within the cord the symptoms are those of a gradually progressing 
paraplegia, which may at first have the picture of a Brown- Sequard paraly- 
sis. Atrophy follows the involvement of the ventral cornua, and vaso- 
motor disturbances may be marked. The reflexes are lost at the level of 
the lesion, but if this be in the thoracic cord, the reflexes are retained in the 
legs. The symptoms are apt to be complicated with those of acute or sub- 
acute myelitis, which may completely alter the clinical picture. Tumors 
•of the spinal membranes are characterized by the early onset and persist- 
ence of the root symptoms, which consist of radiating pains, the girdle sen- 
sation, and hyperesthesia, or anaesthesia in various portions of the trunk. 
There may even be severe pain in the anaesthetic areas. Irritation of the 
motor roots may cause spasm of the muscles supplied, or wasting with 
paralysis. The paraplegia supervenes some time after the occurrence of 
the root symptoms. In the thoracic region the level of the growth is usu- 
ally accurately defined by the level of the pain and the condition of the 
reflexes. 

The diagnosis of tumor within the cord is sometimes easy, the charac- 
teristic features being the constancy and severity of the root symptoms at 
the level of the growth and the progressive paralysis. Caries may cause 
identical symptoms, but the radiating pains are rarely so severe. Cervical 
meningitis simulates tumor very closely, and in reality produces identical 
effects, but the very slow progress and the bilateral character from the 
outset may be sufficient to distinguish it. 

In chronic transverse myelitis the symptoms may, according to Growers, 
simulate tumor very closely and present radiating pains, a sense of con- 
striction, and progressive paralysis. 

The nature of the tumor can rarely be indicated with precision. With 
a marked syphilitic history gumma may naturally be suspected, and with 
coexisting tuberculous disease a solitary tubercle. 

Treatment. — If the possibility of syphilitic infection is present the 
iodide of potassium should be given in large and increasing doses. For 
the severe pains counter-irritation is sometimes beneficial, particularly the 
thermo-cautery; morphia is, however, often necessary. 

In a few instances tumors of the cord or of the membranes are amena- 
ble to surgical treatment. The removal by Horsley of a growth from the 
spinal membranes was one of the most brilliant of recent operations. 

Abscess of flie cord is a rare lesion, of which only 3 or 4 cases have been 
described, all metastatic. It may occur without meningitis. 



SYRINGOMYELIA. 



975 



V. SYRINGOMYELIA. 

Definition. — A gliomatous new formation about the central canal of 
the spinal cord, with cavity formation. 

Etiology and Morbid Anatomy. — Syringomyelia must be dis- 
tinguished from dilatation of the central canal — hydromyelus — slight 
grades of which are not very uncommon either as a congenital condition or 
as a result of the pressure of tumors. The cavity of syringomyelia has a vari- 
able extent in the cord, sometimes running the entire length, but in many 
cases involving only the cervical and thoracic regions or a more limited area. 
It is usually in the dorsal portion of the cord and may extend only into one 
dorsal cornu. The transverse section may be oval or circular or narrow 
and fissure-like. It varies at different levels. The condition is now re- 
garded as a gliosis, a development of embryonal neurogliar tissue in which 
haemorrhage or degeneration takes place with the formation of cavities. 

Of 190 cases, 133 were in men, 57 in women (Schlesinger). A large 
majority of the cases begin before the thirtieth year. The disease has been 
met with in three members of the same family. 

Symptoms. — The clinical features are extremely complex. In the 
classical form there are irregular pains, chiefly in the cervical region; mus- 
cular atrophy develops, which may be confined to the arms, or sometimes 
extends to the legs. The reflexes are increased and a spastic condition 
develops in the legs. Ultimately the clinical picture may be that of an amy- 
otrophic lateral sclerosis. The tactile sensation is usually intact and the 
muscular sense is retained, but painful and thermic sensations are not recog- 
nized, or there may be in rare instances complete anaesthesia of the skin and 
of the mucous membranes (Dejerine). This combination of loss of pain- 
ful and thermic sensations with paralysis of an amyotrophic type is re- 
garded as pathognomonic of the disease. The special senses are usually 
intact and the sphincters uninvolved. Trophic troubles are not uncom- 
mon. Owing to the loss of the pain and heat sensations, the patients are 
apt to injure themselves. Scoliosis also may be present in these cases. 
The loss of painful and thermic impressions is due to the fact that these 
pass to the brain in the peri-ependymal gray matter, particularly that por- 
tion in the dorsal roots, which is almost constantly involved in syringo- 
myelia. The tactile sensation is retained because the postero-lateral column 
is uninvolved. 

Schlesinger, in his recent monograph (1895), recognizes the following 
types: (1) With the classical features above described, which may begin 
in the cervical or lumbar regions: (2) a motor type, with the picture of 
an amyotrophic or a spastic paralysis — the sensation may be undisturbed 
for years; (3) with predominant sensory features, simulating hysterical 
hemiplegia, or with general pain and temperature anaesthesia; (4) with 
pronounced trophic disturbances — to this type belong the cases described 
as Morvan's disease, an affection characterized by neuralgic pains, cuta- 
neous anaesthesia, and painless, destructive whitlows; and (5) the tabetic 
type, either a combination of the symptoms of tabes in the lower, and of 



976 



DISEASES OF THE NERVOUS SYSTEM. 



syringomyelia in the upper extremities, or a pure tabetic symptom-com- 
plex, due to invasion by the gliosis of the dorsal columns (Oppenheim). 
Arthropathies occur in about 10 per cent of the cases. 

In typical cases the diagnosis is easy. The combination of an amyo- 
trophic paralysis, the picture of progressive muscular atrophy of the Aran- 
Duchenne type, with retention of tactile and loss of thermic and painful 
sensation, is probably pathognomonic of the disease. Of affections with 
which it may be confounded, anaesthetic leprosy is the most important, 
since the anaesthesia and the wasting may closely simulate it; but, as a 
rule, in leprosy trophic changes are more or less marked. There is often 
loss of phalanges and there is no characteristic dissociation of sensory im- 
pressions. 

VI. ACUTE MYELITIS." 

Etiology. — Acute myelitis results from many causes, and may affect 
the cord in a limited or extended portion — the gray matter chiefly, or the 
gray and white matter together. It is met with: (a) As an independent 
affection following exposure to cold, or exertion, and leading to rapid loss 
of power with the symptoms of an acute ascending paralysis, (6) As a 
sequel of the infectious diseases, such as small-pox, typhus, and measles. 

(c) As a result of traumatism, either fracture of the spine or very severe 
muscular effort. Concussion without fracture may produce it, but this is 
rare. Acute myelitis, for instance, scarcely ever follows railway accidents. 

(d) In diseases of the bones of the spine, either caries or cancer. This is a 
more common cause of localized acute transverse myelitis than of the diffuse 
affection, (e) In disease of the cord itself, such as. tumors and syphilis; 
in the latter, either in association with gummata, in which case it is usually 
a late manifestation; or it may follow within a year or eighteen months of 
the primary affection. 

Morbid Anatomy. — In localized acute myelitis affecting white and 
gray matter, as met with after accident or an acute compression, the cord is 
swollen, the pia injected, the consistence greatly reduced, and on incising 
the membrane an almost diffluent fluid may escape. In less intense grades, 
on section at the affected area, the distinction between the gray and white 
matter is lost, or is extremely indistinct. The tissue may be injected, or, 
as is often the case, hemorrhagic. It is particularly in these forms, due 
to extension of disease from without or to acute compression, that we 
find definite involvement of the white matter. In other instances the 
gray matter is chiefly affected. There may be localized areas throughout 
the cord in which the gray matter is reduced in consistence and haem- 
orrhagic, the so-called red softening. There may be definite cavity forma- 
tions in these foci. In some cases of disseminated or focal myelitis the 
meninges also are involved and there is a myelomeningitis. And, lastly, 
there are instances in which, throughout a long section of the cord, some- 
times through the lumbar and the greater part of the thoracic, or in the 
thoracic and cervical regions, there is a diffuse myelitis of the gray sub- 
stance. 



ACUTE MYELITIS. 



977 



Histologically the nerve fibres are much swollen and irregularly dis- 
torted, the axis cylinders are beaded, the myelin droplets are abundant, 
and the laminated bodies known as corpora amylacea may be seen. The 
granular fatty cells are also numerous and there may be leucocytes and 
red blood-corpuscles. Changes in the blood-vessels are striking; the smaller 
veins are distended and may show varicosities. The perivascular lymph 
spaces contain numerous leucocytes, and the smaller arteries themselves 
are frequently the seat of hyaline thrombi. The ganglion cells are swollen 
and irregular in outline, the protoplasm is extremely granular and vacuo- 
lated, and the nuclei, though usually invisible, may show signs of division, 
and the processes of the cells are not seen. 

In cases which persist for some time we have an opportunity of seeing 
the later stages of acute myelitis. The acute, inflammatory, hyperaemic or 
red softening is succeeded by stages in which the affected area becomes 
more yellow from gradual alteration of the blood-pigment, and finally white 
in color from the advancing fatty degeneration. In cases of compression 
myelitis, a sclerosis may gradually be produced with the anatomical picture 
of a chronic diffuse myelitis. 

Symptoms. — (a) Acute Diffuse Myelitis. — This form may follow ex- 
posure to cold, or occurs in connection with syphilis or one of the infec- 
tious diseases, or is seen in a typical manner in the extension from in- 
juries or from tumor. The onset, though scarcely so abrupt as in hagmor- 
rhage, may be sudden; a person may be attacked on the street and have 
difficulty in getting home. In some instances, the onset is preceded by 
pains in the legs or back, or a girdle sensation is present. It may be 
marked by chills, occasionally by convulsions; fever is usually present from 
the beginning — at first slight, but subsequently it may become high. 

The motor functions are rapidly lost, sometimes as quickly as in Lan- 
dry's ascending paralysis. The paraplegia may be complete, and, if the 
myelitis extends to the cervical region, there may be impairment of mo- 
tion, and ultimately complete loss of power of the upper extremities as 
well. The sensation is lost, but there may at first be hyperesthesia. The 
reflexes in the initial stage are increased, but in acute central myelitis, un- 
less limited in extent to the thoracic and cervical regions, the reflexes are 
usually abolished. The rectum and bladder are paralyzed. Trophic dis- 
turbances are marked; the muscles waste rapidly; the skin is often con- 
gested, and there may be localized sweating. The temperature of the 
affected limbs may be lowered. Acute bed-sores may develop over the sacrum 
or on the heels, and sometimes a multiple arthritis is present. In these 
acute cases the general symptoms become greatly aggravated, the pulse 
is rapid, the tongue becomes dry; there is delirium, the fever increases, and 
may reach 107° or 108°. 

The course of the disease is variable. In very acute cases death follows 
in from five to ten days. The cases following the infectious diseases, par- 
ticularly the fevers and sometimes syphilis, may run a milder course. 

The diagnosis of this variety of acute myelitis is rarely difficult. In 
common with the acute ascending paralysis of Landry, and with certain 
cases of multiple neuritis, it presents a rapid and progressive motor paraly- 



978 



DISEASES OF THE NERVOUS SYSTEM. 



sis. From the former it is distinguished by the more marked involvement 
of sensation, the trophic disturbances, the paralysis of bladder and rectum, 
the rapid wasting, the electrical changes, and the fever. From acute cases 
of multiple neuritis it may be more difficult to distinguish, as the sensory 
features in these cases may be marked, though there is rarely, if ever, in 
multiple neuritis complete anaesthesia; the wasting, moreover, is more rapid 
in myelitis. The bladder and rectum are rarely involved — though in ex- 
ceptional cases they may be — and, most important of all, the trophic 
changes, the development of bullae, bed-sores, etc., are not seen in multiple 
neuritis. 

(b) Acute Transverse Myelitis. — The symptoms naturally differ with the 
situation of the lesion. 

(1) Acute transverse myelitis in the thoracic region, the most common 
situation, produces a very characteristic picture. The symptoms of onset 
are variable. There may be initial pains or numbness and tingling in the 
legs. The paralysis may set in quickly and become complete within a 
few days; but more commonly it is preceded for a day or two by sensa- 
tions of pain, heaviness, and dragging in the legs. The paralysis of the 
lower limbs is usually complete, and if at the level, say, of the sixth thoracic 
vertebra, the abdominal muscles are involved. Sensation may be partially 
or completely lost. At the onset there may be numbness, tingling, or even 
hyperesthesia in the legs. At the level of the lesion there is often a zone 
of hyperesthesia, which is discovered by passing a test-tube containing hot 
water along the spine, when the sensation of warmth changes to one of 
actual pain. A girdle sensation may occur early, and when the lesion is in 
this situation it is usually felt between the ensiform and umbilical regions. 
The reflex functions are variable. There may at first be abolition of the 
reflexes; subsequently, the reflexes, which pass through the segments lower 
than the one affected, may be exaggerated and the limbs may take on a 
condition of spastic rigidity. It does not always happen, however, that the 
reflexes are increased in a total transverse lesion of the cord. They may be 
entirely lost, as first pointed out by Bastian. That this is not due to the 
preliminary shock is shown by the fact that the abolition of the reflexes 
may continue for four or more months. The trophic changes are not 
marked. The muscles become extremely flabby, but not wasted in an ex- 
treme degree; subsequently rigidity develops. If the gray matter of the 
lumbar cord is involved, the flaccidity persists and the wasting may be 
considerable. The reaction of degeneration is not present. The tempera- 
ture of the paralyzed limbs is variable. It may at first rise, then fall and 
become subnormal. Lesions of the skin are not uncommon, and bed-sores 
are apt to form. There is at first retention of urine and subsequent incon- 
tinence. If the lumbar centres are involved, there are from the outset 
vesical symptoms. The urine is alkaline in reaction and may rapidly be- 
come ammoniacal. The bowels are constipated and there is usually incon- 
tinence of the feces. Some writers attribute the cystitis associated with 
transverse myelitis to disturbed trophic influence. 

The course of complete transverse myelitis depends a good deal upon 
its cause. Death may result from extension. Segments of the cord may 



TOPICAL DIAGNOSIS. 



979 



be completely and permanently destroyed, in which case there is persistent 
paraplegia. The pyramidal fibres below the lesion undergo the secondary 
degeneration, and there is an ascending degeneration of the dorsal me- 
dian columns. If the lower segments of the cord are involved the legs 
may remain flaccid. In some instances a transverse myelitis of the thoracic 
region involves the ventral horns above and below the lesion, producing 
flaccidity of the muscles, with wasting, fibrillar contractions, and the reac- 
tion of degeneration. More commonly, however, in the cases which last 
many months there is more or less rigidity of the' muscles with spasm or per- 
sistent contraction of the flexors of the knee. 

(2) Transverse Myelitis of the Cervical Region. — If the lesion is at the 
level of the sixth or seventh cervical nerves, there is paralysis of the upper 
extremities, more or less complete, sometimes sparing the muscles of the 
shoulder. Gradually there is loss of sensation. The paralysis is usually 
complete below the point of lesion, but there are rare instances in which the 
arms only are affected, the so-called cervical paraplegia. In addition to the 
symptoms already mentioned there are several which are more characteristic 
of transverse myelitis in the cervical region, such as the occurrence of 
vomiting, hiccough, and slow pulse, which may sink to 20 or 30, pupillary 
changes — myosis — sometimes attacks of dysphagia, dyspnoea, or syncope. 

Treatment of Acute Myelitis. — In the rapidly developing form 
due either to a diffuse inflammation in the gray matter or to transverse 
myelitis, the important measures are: Scrupulous cleanliness, care and 
watchfulness in guarding against bed-sores, the avoidance of cystitis, either 
by systematic catheterization or, if there is incontinence, by a carefully 
adjusted bed urinal, or the use of antiseptic cotton-wool repeatedly changed. 
In an acute onset in a healthy subject the spine may be cupped. Counter- 
irritation is of doubtful advantage. Chapman's ice-bag is sometimes useful. 
No drugs have the slightest influence upon an acute myelitis, and even in 
subjects with well-marked syphilis neither mercury nor iodide of potassium 
is curative. Tonic remedies, such as quinine, arsenic, and strychnia, may 
be used in the later stages. When the muscles have wasted, massage is bene- 
ficial in maintaining their nutrition. Electricity should not be used in the 
early stages of myelitis. It is of no value in the transverse myelitis in the 
thoracic region with retention of the nutrition in the muscles of the leg. 



Y. DIFFUSE AND FOCAL DISEASES OF THE BKAIK 
I. TOPICAL DIAGNOSIS. 

Only certain regions of the brain give localizing symptoms. These 
are the cortical motor centres, the speech centres, the centres for the spe- 
cial senses, and the tracts which connect these cortical areas with each 
other and with other parts of the nervous system. 

The following is a brief summary of the effects of lesions from the 
cortex to the spinal cord: 



980 



DISEASES OF THE NERVOUS SYSTEM. 



1. The Cerebral Cortex— (a) Destructive lesions of the motor cortex 
(central gyri, lobulus paracentral, posterior portions of the three frontal 
gyri, especially of the inferior) cause paralysis in the muscles of the oppo- 
site side of the body. The paralysis is at first flaccid, but the spastic condi- 
tion subsequently develops. The extent of the paralysis depends upon that 
of the lesion. It is apt to be limited to the muscles of the head or of an ex- 
tremity, giving rise to the cerebral monoplegias (Fig. 11, 1). One group of 
muscles may be much more affected than others, especially in lesions of 
the highly differentiated • area for the upper extremity. It is uncommon to 
find all the muscle groups of an extremity equally involved in cortical 
monoplegia. Very rarely through small bilaterally symmetrical lesions 
monoplegia of the tongue may result without paralysis of the face. A 
lesion may involve centres lying close together or overlapping one another, 
thus producing associated monoplegias — e. g., paralysis of the face and 
arm, or of the arm and leg, but not of the face and leg without involve- 
ment of the arm. Very rarely the whole motor cortex is involved, causing 
paralysis of the opposite side — cortical hemiplegia. Usually in such in- 
stances there is marked recovery, so that only a monoplegia persists. 

The motor area corresponds also, at least in large part, to the region 
of the cortex in which the impulses concerned in general bodily sensation 
(cutaneous sensibility, muscle sense, visceral sensations) first arrive (the 
somaBsthetic area). Combined with the muscular weakness there is usually 
some disturbance of sensations, particularly of those of the muscular sense. 
The stereognostic sense is very often affected. In brachial monoplegia, for 
example, a coin or a knife when placed in the hand of the paralyzed limb, 
the patient's eyes being closed, is not recognized, owing to inappreciation 
of the form and consistence of the object, and this even though the slight- 
est tactile stimulus applied to the fingers or surface of the hand is felt and 
may be correctly localized. The sense of touch, pain, and temperature may 
be lowered, but usually not markedly unless the superior and inferior 
parietal lobules are involved in addition to the central gyri. Paresthesias 
and vaso-motor disturbances are common accompaniments of paralyses of 
cortical origin. Here, too, the stereognostic sense is frequently involved. 

(b) Irritative lesions cause localized spasms as described above (page 
917). The most varied muscle groups corresponding to particular move- 
ment forms may be picked out. If the irritation be sudden and severe, 
typical attacks of Jacksonian epilepsy may occur. These convulsions are 
usually preceded and accompanied by subjective sensory impressions. Ting- 
ling or pain, or a sense of motion in the part, is often the signal symptom 
(Seguin), and is of great importance in determining the seat of the 
lesion. 

Lesions are often both destructive and irritative, and we then have 
combinations of the symptoms produced by each. For instance, certain 
muscles may be paralyzed, and those represented near them in the cortex 
may be the seat of localized convulsions, or the paralyzed limb itself may 
be at times subject to convulsive spasms, or muscles which have been con- 
vulsed may become paralyzed. The close observation of the sequence of 
the symptoms in such cases often makes it possible to trace the progress 



TOPICAL DIAGNOSIS. 



981 



of a lesion involving the motor cortex. In these eases the most frequent 
cause is a developing tumor, though sometimes local thickenings of the 
membranes of the brain, small abscesses, minute haemorrhages, or fragments 
of a fractured skull must be held responsible. 

In another section lesions involving the centres for the special senses 
are considered, and we shall simply refer to them here. The symptoms 
caused by lesions of the speech centres will be described under aphasia, and 
it is only necessary to note here the near situation of the motor speech area 
(Broca's centre) in the left inferior frontal convolution to the centres for 
the face and arm on that side, and to state that motor aphasia is often 
associated with monoplegia of the right side of the face and the right arm. 
Accompanying the paralysis, following a J acksonian fit, of the right face or 
arm there is often a transient motor aphasia. 

According to Flechsig, the sensori-motor centres are limited to tolerably 
circumscribed areas in the cortex, which differ from other portions in that 
they are provided with projection fibres which connect them with lower 
centres. The remaining areas of the cortex, amounting, he believes, to 
about two thirds of the whole, are devoid of projection fibres and are con- 
cerned entirely in associative activities. These latter areas, the " association 
centres" of Flechsig, are three in number: (1) The anterior association 
centre, including the whole of the frontal lobe in front of the somgesthetic 
area; (2) the middle association centre, corresponding to the cortex of the 
island of Eeil; and (3) the large, posterior association centre, including the 
precuneus, the superior and inferior parietal lobules, the supramarginal 
and angular gyri, and the whole of the temporal and occipital lobes except 
the auditory and visual sensory areas. 

Flechsig attributes the higher psychic functions, especially those con- 
nected with the personality of the individual, to the anterior association 
centres, while the intellectual activities which have to do with knowledge 
of the external world he believes correspond to the functions of the large 
posterior association centre. Whether these views be true, and, if so, in how 
far they may be applied practically in the localization of diseases, especially 
of the mind, the future has to decide. 

2. Centrum Semiovale. — Lesions in this part may involve either projec- 
tion fibres (motor or sensory) or association fibres. If involvement of the 
motor path cause paralysis, this has the distribution of a cortical palsy when 
the lesion is near the cortex, and of a paralysis due to a lesion of the in- 
ternal capsule when it is near that region. These lesions of the motor 
fibres may be associated with symptoms due to interruption in the other 
systems of fibres running in the centrum semiovale; there may be sensory- 
disturbances — hemianesthesia and hemianopia — and if the lesion is in the 
left hemisphere one of the different forms of aphasia may accompany the 
paralysis. 

3. Corpus Callosum. — This may be congenitally absent without symp- 
toms. An acute lesion involving a large portion of the corpus callosum 
may, however, yield symptoms suggestive of its localization in this region. 
In the case recorded by Eeinhard, in which the situation of the lesion was 
suspected ante-mortem, there was disturbance of equilibration (without 



9S2 



DISEASES OF THE NERVOUS SYSTEM. 



vertigo) and of the synergetic movements of botli halves of the body. The 
autopsy revealed a gliosarcoma which had destroyed the posterior three 
fourths of the corpus callosum. In Bristowe's 4 cases there existed, as 
symptoms common to all, pain in the head and partial or complete hemi- 
plegia, with gradual extension of the paralysis to the opposite side of the 
body. Toward the end of life there was disturbance of speech, difficulty 
in deglutition, incontinence of urine and faeces and dementia. Here the 
symptoms have in them nothing that can be looked upon as pathognomonic; 
indeed, many of the phenomena were doubtless dependent upon involvement 
of the projection and association fibres of the centrum semiovale. 

In animals in which the corpus callosum has been cut experimentally 
progressive emaciation has been mentioned as a characteristic phenomenon. 

4. Internal Capsule (Fig. 4). — Through this pass within a rather 
narrow area all, or nearly all, of the projection fibres (both motor and 
sensory) which are connected with the cerebral cortex. It is divided into 
an anterior limb, a knee, and a posterior limb, the latter consisting of a 
thalamo-lenticular portion (its anterior two thirds) and a retro-lenticular 
portion (its posterior third). In considering the effects of a given focal 
lesion involving the fibres of the internal capsule, it is not to be forgotten 
that the relations of the two limbs of the capsule to one another and to the 
knee vary considerably in different horizontal planes. Much of the con- 
fusion in the bibliography is dependent upon neglect to describe the hori- 
zontal level of the lesion, as well as its situation in an antero-posterior di- 
rection. The principal bundle passing through the anterior limb of the 
capsule is that which connects the frontal gyri and the medial bundle in 
the base of the peduncle (crus) with the nuclei of the pons. These fibres 
are centrifugal, and innervate chiefly the lower motor nuclei governing 
bilaterally innervated muscles, especially those of the eyes, head, neck, and 
probably those of the mouth, tongue, and larynx. In lower horizontal 
planes these fibres are situated near the knee of the capsule. It is the region 
of the knee of the capsule which transmits especially the fibres passing 
from the cerebral cortex to the nuclei of the facial, hypoglossal and third 
nerves. The path which supplies the nuclei governing the muscles used 
in speech passes through the knee. 

The pyramidal tract goes through the thalamo-lenticular portion of the 
capsule. The motor fibres are arranged according to definite muscle groups, 
or rather movement forms, those for the movements of the arm being ante- 
rior to those for the leg. The number of fibres for a given muscle group 
corresponds rather to the degree of complexity of the movements than to 
the size of the muscles concerned. Thus the areas for the fingers and toes 
are relatively large. 

The fibres to the somaesthetic area of the cortex — that is, those from the 
ventro-lateral group of nuclei of the thalamus and the tegmental radia- 
tions — carrying impulses concerned in general bodily sensation, pass up- 
ward through the posterior part of the thalamo-lenticular portion of the 
capsule. Some of these fibres pass through the anterior two thirds of the 
posterior limb alongside of the fibres of the pyramidal tract. 

Through the retro-lenticular portion of the posterior limb, opposite the 



TOPICAL DIAGNOSIS. 



983 



posterior third of the lateral surface of the thalamus, pass (1) the fibres 
carrying impulses concerned in the sensations of the opposite visual field 
(optic radiation from the lateral geniculate body to the visual sense area in 
the occipital cortex); (2) the fibres carrying impulses concerned in audi- 
tory sensations (-radiation from the medial geniculate body to the auditory 
sense area in the cortex of the temporal lobe); (3) the fibres (probably cen- 
trifugal) connecting the cortex of the temporal lobe with the nuclei of 
the pons. 

With this preliminary knowledge concerning the internal capsule, it is 
not difficult to understand the symptoms which result when it is diseased. 

Since here all the fibres of the upper motor segment are gathered to- 
gether in a compact bundle, a lesion in this region is apt to cause complete 
hemiplegia of the opposite side, followed later by contractures; and if the 
lesion involves the hinder portion of the posterior limb there is also hemi- 
ansesthesia, including even the special senses (Fig. 4). As a rule, however, 
lesions of the internal capsule do not involve the whole structure. The 
disease usually affects mainly either the anterior or posterior portions, and 
even in instances in which at first the symptoms point to total involvement, 
there is a disappearance often of a large part of the phenomena after a 
short time. Thus when the pyramidal tract is destroyed (lesion of the 
thalamolenticular portion of the capsule) the arm may be affected more 
than the leg, or vice versa. The facial paralysis is usually slight, though 
if the lesion be well forward in the capsule the paralysis of the face and 
tongue may be marked. 

Hemianesthesia alone without involvement of the motor fibres, due to 
disease of the capsule, is rare. There is usually also at least partial paraly- 
sis of the leg. "When the retro-lenticular portion of the capsule is destroyed 
the hemianesthesia is accompanied by hemianopsia, disturbance of hearing, 
and sometimes of smell and taste. The occurrence of hemichorea, marked 
tremor, or hemiathetosis after a capsular hemiplegia points to the involve- 
ment of the thalamus or of the hypothalamic region in the lesion. 

Charcot and others have described cases in which as a result of disease 
of the internal capsule there has been paralysis of the face and leg without 
involvement of the arm. In such instances the lesion is linear, extending 
from the posterior part of the anterior limb of the internal capsule back- 
ward and lateralward to the leg region in the posterior limb of the capsule, 
the region for the arm escaping. 

Capsular lesions when pure are not usually accompanied by aphasic 
symptoms, alexia, or agraphia. A " subcortical " motor aphasia may result 
if the lesion is bilateral, as in pseudo-bulbar paralysis, or if on the left 
side it is so extensive as to destroy the fibres connecting Broca's convolu- 
tion with the opposite hemispheres, as well as the pyramidal fibres on the 
same side. 

5. Crura (Cerebral Peduncles). — From this level through the pons, me- 
dulla, and cord the upper and lower motor segments arc represented, the 
first by the fibres of the pyramidal tracts and by the fibres which go from 
the cerebral cortex to the nuclei of the cerebral nerves, the Latter by the 
motor nuclei and the nerve fibres arising from them. Lesions often alfect 



984 DISEASES OF THE NERVOUS SYSTEM. 



both motor segments, and produce paralyses having the characteristics of 
each. Thus a single lesion may involve the pyramidal tract and cause a 
spastic paralysis on the opposite side of the body, and also involve the 
nucleus or the fibres of one of the cerebral nerves, and so produce a lower 
segment paralysis on the same side as the lesion — crossed paralysis. In the 
crus the third and fourth cerebral nerves run near the pyramidal tract, and 
a lesion of this region is apt to involve them or their nuclei, causing partial 
paralysis of the muscles of the eye on the same side as the lesions, combined 
with a hemiplegia of the opposite side (Fig. 10, 3). 

The optic tract also crosses the crus and may be involved, giving hemi- 
anopsia in the opposite halves of the visual fields. 

If the tegmentum be the seat of a lesion which does not involve the base 
of the peduncle (or pes) there may be disturbances of cutaneous and mus- 
cular sensibility, ataxia, disturbances of hearing, or oculo-motor paralysis. 
An oculo-motor paralysis of one side, accompanied by a hemi-ataxia of the 
opposite side, appears to be especially characteristic of a tegmental lesion. 

6. Corpora Quadrigemina. — Anatomical studies point to the view that 
the superior colliculus (anterior quadrigeminal body) represents the most 
important subcortical central organ for the control of the eye-muscle nuclei. 
This is- supported to a certain extent by clinical evidence, though as yet 
but few cases have been carefully studied. Sight is only slightly, if at all, 
disturbed when the superior colliculus is destroyed. The pupil is usually 
widened, and the pupillary reaction, both to light and on accommodation, 
interfered with. Apparently actual paralysis of the eye muscles does not 
occur unless the nucleus of the third nerve ventral to the aqueduct be also 
injured. 

The inferior colliculus (posterior quadrigeminal body), on the other 
hand, has been shown by anatomical study to be an important way-station 
in the auditory conduction-path. A large part of the lateral lemniscus 
ends in its nucleus, and from it emerge medullated fibres which pass through 
the brachium quadrigeminum inferior to the medial geniculate body. 
Thence a large bundle runs through the retro-lenticular portion of the 
internal capsule to the auditory sense area in the cortex of the temporal 
lobe. 

Weinland has collected 19 cases of tumors of the corpora quadrigemina 
from the bibliography; in 9 of these auditory disturbances were espe- 
cially noted. Since the central auditory path of each side receives im- 
pulses from both ears, lesion of the colliculus on one side may dull the 
hearing on both sides, though the opposite ear is usually the more defec- 
tive. Lesion of the inferior colliculus may be accompanied by disturb- 
ance of mastication, owing to paralysis of the descending (mesencephalic) 
root of the trigeminus. The fourth nerve may also be involved. The 
ataxia which sometimes accompanies lesions of the corpora quadrigemina 
is probably to be referred to disturbance in conduction in the medial lem- 
niscus. 

7. Pons and Medulla Oblongata. — Lesions involving the pyramidal 
tract, together with any one of the motor cerebral nerves of this region, 
cause crossed paralysis. A lesion in the lower part of the pons is apt to 



TOPICAL DIAGNOSIS. 



985 



cause a lower-segment paralysis of the face on the same side (destruction 
of the nucleus of the facial nerve or of its root fibres) and a spastic paraly- 
sis of the arm and leg on the opposite side (injury to pyramidal tract) (Fig. 
10, 4). The abducens, the motor part of the trigeminus, and the hypo- 
glossals nerves may also be paralyzed in the same manner. When the cen- 
tral fibres to the nucleus of the hypoglossus are involved a peculiar form 
of anarthria results. If the nucleus itself be diseased, swallowing is inter- 
fered with. 

When the sensory fibres of the fifth nerve are interrupted, together 
with the sensory tract (the medial lemniscus or fillet) for the rest of the 
body, which has already crossed the middle line, there is a crossed sensory 
paralysis — i. e., disturbed sensation in the distribution of the fifth on the 
side of the lesion, and of all the rest of the body on the opposite side. 

A paralysis of the external rectus muscle of one eye and of the internal 
rectus of the other eye (conjugate paralysis of the muscles which turn the 
eyes to one side), in the absence of a " forced position " of the eyeballs, is 
highly characteristic of certain lesions of the pons. In such cases the in- 
ternal rectus may still be capable of functioning on convergence, or when 
the eye to which it belongs is tested independently of that in which the 
external rectus is paralyzed. This form of paralysis is found, as a rule, 
only when the lesion lies just in front of the abducens or involves the 
nucleus itself, or includes, besides the root fibres of the abducens, that por- 
tion of the formatio reticularis that lies between them and the fasciculus 
longitudinalis medialis- (von Monakow). The cases of conjugate paralysis 
just referred to may be complicated by other disturbances of the eye-muscle 
movements, in which case the interpretation of the symptoms may be ren- 
dered difficult. The facial nerve is often involved in these paralyses. 

In lesions of the pons the patient often has a tendency to fall toward 
the side on which the lesion is, probably on account of implication of the 
middle peduncle of the cerebellum (brachium pontis). Still more frequent 
is the simple motor hemi-ataxia consequent upon lesion of the medial lem- 
niscus, and perhaps of longitudinal bundles in the formatio reticularis. 
This is often accompanied by disturbance of muscular and cutaneous 
sensations. Only when the lesion is very extensive are there disturb- 
ances of hearing (involvement of the lateral lemniscus or corpus trape- 
zoideum). 

The symptoms produced by involvement of the different cerebral nerves 
will be considered in detail in another section. 

8. Cerebellum. — The functions of this part of the brain are still under 
consideration. Luciani, whose monograph is exhaustive, regards it as " an 
end organ, directly or indirectly related to certain peripheral sensory organs 
and in direct efferent relationship with certain ganglia of the cercbro-spinal 
axis, and indirectly with the motor apparatus in general. It is functional lv 
homogeneous, each part exercising the functions of the whole, but having 
special relations to the muscles of the corresponding side of the body " 
(Krauss). 

Lesions of the lateral lobes affect the corresponding side of the body, 
while lesions of the middle lobe (vermis) affect both sides. Partial removal 
62 



986 



DISEASES OF THE NERVOUS SYSTEM. 



is followed by transient muscular weakness; complete removal by extreme 
incoordination. Its one important function would appear to be the co- 
ordination of the muscular movements. ; . 

In monkeys the symptoms differ much at different periods after the 
operation. During the first five or six days irritation phenomena predom- 
inate. There is, according to Luciani, asthenia, atony of the muscles, and 
astasia on the side of the body operated upon. The animal can not stand 
or walk. All these symptoms may gradually disappear in the course of a 
few months. 

The experiments of J. S. Risien Eussell do not entirely confirm the ob- 
servations of Luciani. In the first place, the occurrence of asthenia is not 
constant, and as to atony, while the patellar tendon reflexes are sometimes 
absent, they are as a rule intact in pure cerebellar lesions. There may be 
even muscular rigidity instead of atony. KusselPs experiments make it 
seem likely that the cerebellar hemisphere of one side exercises constantly 
an inhibitory effect upon the activities of the cerebral hemisphere of the 
opposite side (probably by way of the brachium conjunctivum). Thus after 
removal of one cerebellar hemisphere he found that much milder faradic 
stimulation of the contra-lateral motor area would call forth movements 
of the arm and leg than that necessary to stimulate the homo-lateral motor 
area. The epileptic seizures following the administration of absinthe were 
far greater on the side of ablation. It is not impossible that the explana- 
tion of the epileptiform attacks by no means rare in cerebellar disease is 
here to be sought. 

W. C. Krauss has analyzed the lesions and symptoms in 100 cases of 
disease of this part. The morbid conditions were as follows: Sarcoma in 
22 cases; tubercle in 22; glioma in 18; abscess in 10; tumor of unspecified 
origin in 13; cyst in 7; and 1 case each of softening, endothelioma, cyst 
and sarcoma, cancer, gumma, fibroma, and haemorrhage. The left lobe was 
affected 32 times, the right lobe 32 times, and the middle lobe 17 times. 
Thus tumor constituted by far the most important affection. There may be 
no symptoms whatever if it is in one hemisphere only and does not involve 
the middle lobe. There are not only instances of complete absence of one 
whole hemisphere, but also of extensive bilateral disease which throughout 
life have yielded no noticeable symptoms. Other portions of the brain 
appear to be able to take on the functions normally performed by the cere- 
bellum. The most common symptoms in tumor of the cerebellum are as 
follows: 

Vertigo, which is more constant in this than in affections of any other 
region of the brain. Some believe this to be due to involvement of the 
nervus vestibularis or its nuclei of termination, by means of which the 
semicircular canals are connected with the cerebellum. The symptom was 
present in 48 of the cases of Krauss's collection, not reported in 43. The 
vertigo appears to be entirely independent of the ataxia. Though most 
•frequently associated, either symptom may be present without the other. 
The vertigo of cerebellar disease is often associated with the feeling that 
objects are revolving about the body, or that the body itself is moving. 
Headache was present in 83 cases. Vomiting occurred in 69 cases, not re- 



TOPICAL DIAGNOSIS. 987 

ported in 23. Optic neuritis was found in 66 cases, not reported in 23. 
Very serious disturbances of vision may result from pressure on the aque- 
ductus cerebri, leading to increased pressure in the third ventricle; this, 
through bulging of the floor, can directly injure the chiasm or optic nerve. 

Of symptoms which are designated as more particularly cerebellar, 
ataxia is the most important. In cerebellar ataxia the gait is irregular and 
staggering, often zigzag, and in attempting to walk the patient sways to 
and fro like a drunken man (demarche cVivresse of the French writers). As 
a rule, the patient walks and tends to fall toward the affected side, but the 
rule is not certain. The ataxia of cerebellar disease is to be sharply differ- 
entiated from the ataxia of tabes dorsalis, from cortical ataxia, and prob- 
ably from the ataxia accompanying diseases of the tegmental portion of the 
pons and cerebral peduncle. Cerebellar ataxia is both static and dynamic. 
The opening or closing of the eyes is of less influence than in spinal ataxia. 
Very important for differential diagnosis is the fact that when the patient 
lies in bed movements tolerably well coordinated can be carried out. The 
coarse nature of the incoordination distinguishes cerebellar ataxia from 
that due to lesion of the cerebral cortex. In the latter the finer movements 
(buttoning, etc.) are especially apt to be involved, and there is usually 
hemi-paresis or mono-paresis, 'and often disturbance of muscular sense and 
of the stereognostic sense (von Monakow). Cerebellar ataxia may depend 
upon the withdrawal of the influence of the cerebellum upon the cerebrum. 

Paresis of the trunk muscles, manifest in an inability to perform the 
movements of bending, erection, and lateral flexion of the trunk, may be 
present (Hughlings Jackson). Eisien Eussell holds that the paralysis is 
I probably directly due to the withdrawal of the cerebellar influence from 
the muscles." 

Other less constant but suggestive symptoms are neuralgic pains in the 
region of the neck and occiput; blocking of the venae Galeni and dilatation 
of the lateral ventricles, causing in children hydrocephalus; pressure on 
the mid-brain, pons, or medulla oblongata, producing paralysis of the cere- 
bral nerves, rhythmical contractions of the head or extremities, nystagmus, 
tremor, anarthria, auditory or visual disturbances. There may be glyco- 
suria and bilateral rigidity from pressure on the motor paths. Sudden 
death may occur. Forced movements, especially rotation of the trunk, 
forced positions (of the head or trunk), and a peculiar forced position of the 
eyes (one turned downward and to the side, the other upward and inward) 
are almost pathognomonic of disease of one brachium pontis (middle cere- 
bellar peduncle). 

The reflexes are very variable; they were absent in 12 cases. In pure 
cerebellar lesion they are probably intact or exaggerated, but when the 
cerebellar disease involves other structures, directly or indirectly, through 
action at a distance, or when there is associated disease of the spinal tracts, 
the reflexes may be abolished. 

Symptoms of general mental disturbance may accompany cerebellar dis- 
ease, but they are not characteristic. There is often irritability, enfeebled 
memory, and toward the end sopor and coma. 



988 



DISEASES OF THE NERVOUS SYSTEM. 



II. APHASIA. 

Speech disorders give important information as to the position of 
lesions of the nervous system, and it is for this reason that they are con- 
sidered here. 

The studies of Dax, Broca, Bastian, Kussmaul, Lichtheim, and others 
have done much to widen our knowledge of this very difficult subject. The 
student is referred to the works of these authors, and especially to the 
recent monographs. 

The speech movements, just as all other voluntary movements, require 
not only the motor mechanism, but also the sensory, and we have, as com- 
posing the speech mechanism, a sensory or receptive part as well as a motor 
or emissive part. These two parts reach to, and are controlled by, the 
mechanism that underlies the intellectual process. 

The muscles which are used in the production of articulate speech are 
many and widely distributed; thus the respiratory muscles, the muscles of 
the larynx, the pharynx, the tongue, the lips, and those which move the 
jaws, are all brought into play during speech. These muscles are all active 
in other less complicated movements; for instance, respiration, crying, 
sucking, etc., and these comparatively simple movements are represented 
in the gray matter of the lower motor segment, in the pons, medulla, and 
spinal cord. The association of neurones upon which these movements 
depend is made during fcetal life, and is in good working order at the time 
of birth. 

As the child's brain grows and takes control of the spinal centres 
through the medium of the pyramidal tracts, other more complex move- 
ments are developed and special neurones are set apart for this purpose. 
There is, then, a re-representation (Hughlings Jackson) of the finer move- 
ments of these muscles in the upper motor segment. They are localized in 
the central convolutions about the lower part of the Eolandic fissure. All 
these muscles except those of the tongue and lips are used bilaterally, and so 
their movements on each side of the body are represented on both sides of 
the brain. 

This group of movements, which are in part congenital and in part 
acquired during the early months of life, is that from which the delicate 
movements of articulate speech are developed. The structures upon which 
these movements depend make the primary or elementary speech mech- 
anism. 

The cortical centres are in the lower third of the central convolution 
on both sides of the brain. They are bilaterally acting centres, and a 
lesion limited to either one should not produce marked or permanent de- 
fects in speech. This is true for the right side, but on the left Broca's 
convolution is so closely situated that it is usually injured at the same time, 
and so motor aphasia results. 

The Path from Cortex to Lower Motor Centres. — This is made up of the 
pyramidal fibres which go to the nuclei of the pons and medulla, and in 
the internal capsule is situated near the knee. As in the cortex, a uni- 
lateral lesion here causes only slight disturbances of speech due to difficult 



APHASIA. 



989 



articulation, following weakness of the opposite side of the face and tongue. 
On the left side, if the lesion is so near the cortex as to involve the fibres 
which connect Broca's convolution with the primary speech mechanism, 
subcortical motor aphasia is produced. Bilateral lesions (usually in the 
internal capsule, but at times in the cortex) cause speechlessness, with 
paralysis of the muscles of articulation — pseudo-bulbar paralysis. To these 
speech defects Bastian gives the name Aphemia. 

The lower segment of the primary speech mechanism is made up of the 
motor nuclei in the medulla, etc., and the peripheral nerves arising from 
them. Lesions here, if extensive enough — as, for instance, in progressive 
bulbar paralysis — may cause speechlessness — anarthria (Bastian); but usu- 
ally they are more limited, giving various disturbances of articulation. 

As the child learns to speak there is developed in the cortex of the brain 
an association of centres which takes control of the primary speech mechan- 
ism. The child is constantly hearing objects called by names, and he learns 
to associate certain sounds with the look and feel and taste, etc., of certain 
things. When he hears that sound he gets a more or less clear mental 
picture of the object, or, in other words, he has developed certain auditory 
memories. These memories of the sounds of words are stored in what is 
called the auditory speech centre. This centre, which in the majority of 
people is the controlling speech centre, is situated in the first temporal 
convolution on the left side in right-handed people, and on the right side 
in those who are left-handed. The afferent impressions arising in the ears 
reach the temporal lobes, those from each ear going to both sides of the 
brain. From each of these primary, auditory centres impulses are sent to # 
the auditory speech centre in the left hemisphere. The child endeavors, 
and by repeated efforts learns, to make the sounds that he hears, and he 
first becomes able to repeat words, then to speak voluntarily. To do this, 
he has had to learn certain very delicate movements, and so there has been 
developed a special centre in which these movements are localized, which is 
called — 

The Motor Speech Centre. — This is in Broca's convolution, the posterior 
part of the left third frontal convolution. The activity of this centre was 
excited under the influence of impressions received from the auditory speech 
centre. Without this influence it would not have become active (those who 
are born deaf remain dumb) unless some other sensory impressions are made 
to take the place of the auditory influences, as when deaf-mutes are taught 
to speak by the means of sight and touch. Throughout life there is a very 
close interdependence between the motor and the auditory and speech cen- 
tres, and for the perfect functioning of either we must have the normal 
action of both. This is so much so that certain French authors make no 
sharp distinetion,but consider that these centres, with the visual speech cen- 
tre, make together a general speech centre, which is called the sphere of lan- 
guage; a lesion anywhere in this disturbs to a greater or less degree all of 
the psychical components which underlie speech. This is only another way 
of expressing the close interrelation of the different speech centres, but it 
is important in freeing the mind of the student from the conception of the 
different speech processes as being carried on in sharply circumscribed 



990 



DISEASES OF THE NERVOUS SYSTEM. 



independent centres, which is apt to result from a study of the various dia- 
grams that have been devised. The connection between the auditory speech 
centre and the motor speech centre is by fibre tracts, which run in the white 
matter of the island of Eeil. 

In Broca's convolution the movements of the muscles which are repre- 
sented in the primary speech mechanism are rearranged in most delicate 
combinations so as to produce articulate speech — i. e., motor speech memo- 
ries are stored here, or, as Bastian, who considers all cortical centres as 
sensory, would say, " glosso-kinaesthetic memories/' It is from this centre 
that the intellectual speech processes which are carried on in the cortical 
speech areas are transformed into motor activities. We do not as yet know 
the exact anatomical relation between Broca's convolution and the primary 
speech mechanism by which this transformation is brought about. It seems 
certain that Broca's convolution is connected by commissural fibres through 
the corpus callosum with the corresponding area of the right frontal lobe, 
and it can control the speech movements when the more direct path in the 
left pyramidal tract has been interrupted. 

Broca's convolution and the corresponding area in the right brain are 
connected either directly by special pyramidal fibres with the bulbar nu- 
cleus, or, as is more probable, indirectly, through the medium of the cortical 
centres of the primary speech mechanism in the lower part of the Eolandic 
region on both sides. 

The speech centres are in close connection with the rest of the brain 
cortex, and in this way they take part in the general mental activities, of 
t which, indeed, the speech processes form a large part. Some authors have 
assumed that the several sensory elements which go to make a concept are 
brought together in a special region of the brain, and here, as it were, united 
by a name. This is called " the centre for concepts," or " naming centre " 
(Broadbent), but most writers have followed Bastian in considering that the 
supposition of such a centre is unnecessary. 

The mechanism which has been described is that which is developed in 
uneducated people and in children before they have learned to read and 
write, and is of primary importance in all speech processes. As the child 
learns to read he associates certain visual impressions with the speech 
memories he has already acquired, and he then adds to his concepts the 
visual memories of written or printed symbols. Thus memories are stored 
in the speech centre. 

This centre is placed by nearly all authors in the angular and supra- 
marginal convolutions on the left side, where visual impressions from both 
occipital lobes are combined in speech memories. Yon Monakow believes 
that there is no such special centre, but that visual speech memories are 
dependent upon the direct connection of the general visual centres in both 
occipital lobes with the speech sphere. That speech defects result from 
injury to the angular and supramarginal convolutions, he admits; but he 
thinks these are due to an interruption of fibre tracts which lie beneath 
and not to a destruction of a cortical centre. The distinction is, therefore, 
of more theoretical than practical importance. 

In learning to write, the child develops certain delicate movements of 



APHASIA. 



991 



the arm and hand, and thus acquires another method of externalizing his 
speech activities. Whether or not this requires the development of a sepa- 
rate writing centre, apart from the general Eolandic arm centre, or is 
brought about by an evolution of the latter through the medium of Broca's 
convolution, is a vexed question. However this may be, these movements 
are learned under the influence of visual impressions in association with the 
other speech memories, although there is a more direct path, which is used 
in copying unknown characters. Just as the movements of articulate speech 
are constantly under the control of auditory memories, so are the move- 
ments of writing regulated by visual memories; but in this case the other 
speech memories are of great importance. 

With the development of the associations which underlie reading and 
writing, the speech mechanism may be said to be complete, although its 
activities are capable of practically endless extension, as when music or 
foreign languages are learned. 

It will be seen that the cortical speech centres occupy the part of the 
brain near the Sylvian fissure, and that they all receive their blood from 
the Sylvian artery. The posterior part of this region is sensory and the 
anterior is motor. The sensory areas are near the optic radiation and the 
motor are near the general motor tracts, and so with lesions of the pos- 
terior part, hemianopia is apt to be associated with the speech disturbance 
while hemiplegia occurs with disease of the anterior areas. These asso- 
ciations often help to distinguish a sensory from a motor aphasia, but each 
type has special characteristics which must be studied. 

Sensory Aphasia, due to Lesions of the Posterior Part of the 
Speech Area, or to Fibres going to this Region. 

Auditory Aphasia. — Most people in mentally recalling words do so by 
means of their auditory speech memories — i. e., they think of the sound 
of the words, and it is probable, in voluntary speech, that the will acts 
on the motor centre indirectly through the auditory centre. This centre 
is also necessary for reading in such persons. There are certain persons, 
however, in whom the mental processes are carried on by visual memories, 
and in these rare " visuals " the visual speech centres take the predominant 
place in speech usually occupied by the auditory centres. 

Complete abolition of all the auditory speech memories by destruction 
of the first temporal convolution causes the most extensive disturbances of 
speech. Such a person is unable to comprehend speech, either spoken or 
printed. Voluntary speech is much disturbed, and although at first he 
may talk with his words all transposed (paraphasia), he soon becomes 
speechless. Writing is also lost, and he can neither repeat words nor write 
at dictation. He may be able to copy. 

Lesions are often only partial, and the resultant disturbance of speech 
may be simply a difficulty in speech due to the loss of nouns and to para- 
phasia, the writing showing the same defect. He usually understands what 
he hears and reads, and can repeat words and write at dictation. This is' 
the condition Bastian calls "amnesia vcrbalis." The condition may be so 
pronounced that voluntary speech and writing are nearly lost, even when 
the auditory memories can still be aroused by new afferent impressions and 



992 



DISEASES OF THE NERVOUS SYSTEM. 



he is able to understand what is said to him and what he reads. He can 
usually repeat and read aloud. 

The afferent paths, which reach the auditory speech centre from the 
two primary auditory centres, may be destroyed. A lesion to do this must 
be in the white matter beneath the first temporal convolution on the left 
side. Such a lesion would block all auditory impressions coming to the 
centre, and the patient would not be able to understand anything that was 
said to him, could not repeat words nor write from dictation. As the cor- 
tical centres are not disturbed, and the auditory speech memories are still 
present, there is no disturbance of voluntary speech or writing, and the 
patient can read perfectly. This is pure word-deafness or subcortical 
sensory aphasia. 

Visual Aphasia. — Destruction of the visual centre in the angular and 
supramarginal convolutions causes a loss of the visual speech memories, 
and the patient is unable to read printed or written characters. He is 
unable to write — i. e., there is agraphia — and he can not copy. His under- 
standing of spoken words is good, and voluntary speech is normal or only 
slightly paraphasic. 

A subcortical lesion involving the afferent fibres going to the visual 
speech centre causes pure word-blindness (subcortical alexia) — i. e., there 
is inability to understand written or printed words. Voluntary speech and 
writing are good. The patient can not read his own writing except by aid 
of muscle-sense impression, in retracing the letters, either voluntarily or 
passively. Associated with this is always hemianopia. 

Word-deafness and word-blindness are often combined, and at times it 
is not only the tracts that connect the primary auditory and visual cen- 
tres with the speech spheres, but also those which associate them with the 
other sensory centres in the formation of concepts, that are diseased. In 
this case he has not only lost his auditory and visual speech memories, but 
also all of his memories which have to do with hearing and sight, and he 
has mind-deafness and mind-blindness — i. e., he is unable to recognize 
objects when he hears or when he sees them. Further than this, there may 
be a disassociation of all the sensory centres from each other or from the 
higher psychical centre, which is practically the same thing, in which case 
the patient is entirely unable to recognize objects and to use them properly 
— i. e., he has apraxia. Apraxia may occur alone, but is usually associated 
with forms of aphasia. 

Motor Aphasia. — Lesions of Broca's convolution — the posterior part of 
the left third frontal convolution. A complete lesion here causes paralysis 
of the speech movements. The patient may be absolutely dumb or he may 
have retained one or two words or phrases which are believed to be due to 
the activity of the corresponding region of the right brain. He will make 
no effort to repeat words. His mind is comparatively clear, and he under- 
stands what is said to him and is able to read, although there is usually 
some difficulty in this due to the lack of motor speech memories. He will 
not be able to indicate that he has a mental picture of words. This is 
tested by asking him to squeeze the observer's hand or to make expiratory 
efforts the number of times there are syllables in a well-known name. 



APHASIA. 



993 



Voluntary writing is usually lost in cortical motor aphasia, and many 
authors believe that writing movements are controlled from this centre. 
Others, who believe that there is a special writing centre, contend that a 
lesion strictly limited to Broca's convolution would not cause agraphia, and 
cite cases which seem to support their view. If there is much disturbance 
of internal speech, writing will be impaired. 

Subcortical motor aphasia has already been spoken of. It is due to the 
destruction of the fibres which join Broca's convolution to the primary 
speech mechanism. Lesions which have produced this type of aphasia have 
been in the white matter of the left hemisphere near Broca's convolution. 
There is complete loss of the power of speech without any disturbance of 
internal speech. The patient can write perfectly if the hand is not para- 
lyzed and his mental processes are not disturbed. 

Cases of aphasia are rarely simple, and it is often impossible to classify 
them accurately. The problems involved are, in reality, exceedingly com- 
plicated, and the student must not for a moment suppose that cases are as 
straightforward as the various diagrams at first sight would appear to 
indicate. A majority of them are very complex, but with patience the diag- 
nosis of the different varieties can often be worked out. The following 
tests should be applied in each case of aphasia, after the presence or absence 
of paralysis has been determined and whether the patient is right-handed 
or left-handed: (1) The power of recognizing the nature, uses, and relations 
of objects — i. e., whether apraxia is present or not; (2) the power to recall 
the name of familiar objects seen, smelled, or tasted, or of a sound when 
heard, or of an object touched; (3) the power to understand spoken words; 
(4) the capability of understanding printed or written language; (5) the 
power of appreciating and understanding musical tunes; (6) the power of 
voluntary speech — in this it is to be noted particularly whether he misplaces 
words or not; (7) the power of reading aloud and of understanding what he 
reads; (8) the power to write voluntarily and of reading what he has written; 
(9) the power to copy; (10) the power to write at dictation; and (11) the 
power of repeating words. 

The medico-legal aspects of aphasia are of great importance. No general 
principle can be laid down, but each case must be considered on its merits. 
Langdon, in reviewing the whole question, concludes: " Sanity established, 
any legal document should be recognized when it can be proved that the 
person making it can understand fully its nature by any receptive channel 
(viz., hearing, vision, or muscular sense), and can, in addition, express assent 
or dissent with certainty to proper witnesses, whether this expression be by 
spoken speech, written speech, or pantomime." 

Prognosis and Treatment. — In young persons the outlook is good, 
and the power of speech is gradually restored apparently by the education 
of the centres on the opposite side of the brain. In adults the condition is 
less hopeful, particularly in the cases of complete motor aphasia with right 
hemiplegia. The patient may remain speechless, though capable of under- 
standing everything, and attempts at re-education may be futile. Partial 
recovery may occur, and the patient may be able to talk, but misplaces 
words. In sensory aphasia the condition may be only transient, and the 



994 



DISEASES OF THE NERVOUS SYSTEM. 



different forms rarely persist alone without impairment of the powers of 
expression. 

The education of an aphasic person requires the greatest care and pa- 
tience, particularly if, as so often happens, he is emotional and irritable. 
It is best to begin by the use of detached letters, and advance, not too 
rapidly, to words of only one syllable. Children often make rapid progress, 
but in adults failure is only too frequent, even after the most painstaking 
efforts. In the cases of right hemiplegia with aphasia the patient may be 
taught to write with the left hand. 



HI. AFFECTIONS OF THE BLOOD-VESSELS. 

1. HYPEEiEMIA. 

Congestion of the brain has in the past played an important part in 
cerebral pathology. Undoubtedly there are great variations in the amount 
of blood in the cerebral vessels; this is universally conceded, but how far 
these changes are associated with a definite group of symptoms is not quite 
so clear. The whole subject has recently been revised, by E. Geigel, who 
rightly insists that the nutrition of the nerve-cells and the possibility of 
interchange of gases between the blood and the cerebral tissues is dependent 
not only upon the amount of blood in the cerebral vessels, but also upon 
its chemical constitution, and especially, it would appear, upon the velocity 
of the current in the cerebral capillaries. The speed of the blood flow 
in the cerebral capillaries depends, according to this writer, much more 
on the tension of the walls of the vessels than upon the height of the ar- 
terial pressure. In many of the conditions designated as " cerebral hyper- 
emia " there is really a condition of lowered pressure, for with flaccidity 
and widening of the cerebral arteries, due say to paralysis of the sympa- 
thetic, the arterial pressure remaining constant, there must follow as the 
result of the diminution of the tension of the vessel walls a decrease in the 
velocity of the blood-flow. On the other hand, spasm of the cerebral 
arteries, due say to irritation of the sympathetic, gives rise not to " anae- 
mia " as generally is supposed, but through increase of vascular tension 
to a higher velocity of flow through the cerebral capillaries. It has 
been customary to describe cerebral hyperemia as being either active or 
passive (see also Leonard Hill's article in Allbutt's System). 

Thus active hyperemia has been supposed to be associated with febrile 
conditions, with increased action of the heart, chilling of the surface, con- 
traction of the superficial vessels, and with the suppression of certain cus- 
tomary discharges. Among other recognized causes are plethora, func- 
tional irritation, such as is associated with excessive brain work, and the 
action of certain substances, such as alcohol and nitrite of amyl. 

Passive hyperemia was said to result from obstruction in the cerebral 
sinuses and veins, engorgement in the lesser circulation, as in mitral ste- 
nosis, emphysema, from pressure on the superior cava by aneurisms and 
tumors, and in the venous engorgement which takes place in prolonged 



AFFECTIONS OF THE BLOOD-VESSELS. 



995 



straining efforts. In its most intense form it is seen in the compression of 
the superior cava by tumors and in death from strangulation. 

The anatomical changes in congestion of the brain are by no means 
striking. Such an active hyperemia is never visible post mortem. The 
veins of the cortex are distended, the gray matter has a deeper color, and 
its vessels are full. The arteries at the base and in the Sylvian fissures 
contain blood. Nothing, however, can be more uncertain or indefinite than 
the post-mortem appearances of so-called hyperemia of the brain. The 
most intense distention of the vessels is seen in early death during the 
specific fevers, or in the secondary passive congestion due to obstruction in 
the superior cava or in the lesser circulation. In a majority of these cases 
of so-called hyperaemia, while the total mass of blood in the brain may ex- 
ceed the normal by a considerable amount, yet the velocity of the current 
is so much less than normal, that as a result the brain really has a smaller 
supply of blood than is normal — that is, the patient actually suffers from 
cerebral " anaemia " rather than from " hyperaemia." 

Symptoms. — There are no characteristic or constant features of dila- 
tation of the cerebral blood-vessels. It may exist in the most extreme grade 
without the slightest disturbance of the cerebral functions, as is witnessed 
frequently in the pressure by tumors on the superior vena cava. How far 
the headache and delirium of the early stage of the infectious fevers is to 
be assigned to dilatation of the blood-vessels of the brain it is not easy to 
determine. The headache, dizziness, and unpleasant sensations in aortic 
insufficiency and in some instances of hypertrophy of the heart have been 
attributed to the cerebral congestion. 

As a separate clinical entity, congestion of the brain rarely comes 
under observation. I have no knowledge of instances associated with de- 
lirium, fever, insomnia, and convulsions, or of the so-called apoplectiform 
variet}'' described by some writers. Very plethoric persons are subject to 
attacks of headache with flushing of the face and irritability of temper, 
attacks which may recur frequently and are sometimes relieved by bleed- 
ing at the nose. These have usually been attributed to congestion of the 
brain. When the so-called passive hyperaemia reaches a high grade, there 
may be torpor, dulness of the intellect, and ultimately deep coma. 

Leube suggests that the symptoms usually referred to active hyperemia 
in the acute infectious diseases, like diphtheria and erysipelas, or in the 
instances in which hypertrophy of the heart accompanies disease of the 
kidneys, may after all be toxic in origin, rather than due to alteration in 
the circulatory relations. At any rate, he believes that it is not possible 
to make a diagnosis of such a hyperaemia. Flushing of the face is by no 
means a safe guide. Possibly an examination of the eye-grounds may be 
helpful. 

2. Anjemia. 

This may be induced by loss of blood, either quickly, as in haemor- 
rhage, or gradually, as in the severe primary and secondary anaemias. 
The anaemia may be local and due to causes which interfere with the blood 
supply to the brain, as narrowing of the vessels by endarteritis, pressure, 



996 



DISEASES OF THE NERVOUS SYSTEM. 



narrowing of the aortic orifice, or it may follow an unequal distribution 
of the blood in consequence of dilatation of certain vascular territories. 
Thus, rapid distention of the intestinal vessels, such as occurs after the 
removal of ascitic fluid, may cause sudden death from cerebral anaemia. 
The commonest illustration of this is the fainting fit from emotion, in 
which the blood supply to the brain is insufficient on account of the dimin- 
ished arterial pressure. Anaemia of the cerebral vessels may be caused 
by pressure of fluid in the ventricles. The partial anaemia results from 
obliteration of branches of the circle of Willis by embolism or thrombosis. 
Ligature of one carotid sometimes causes a transient marked anaemia and 
disturbance of function on one side of the brain. 

The anatomical condition of the brain in anaemia is very striking. 
The membranes are pale, only the large veins are full, the small vessels 
over the gyri are empty, and an unusual amount of cerebro-spinal fluid is 
present. On section both the gray and white matter look extremely pale 
and the cut surface is moist. Very few puncta vasculosa are seen. 

Symptoms. — The effects of anaemia of the brain are well illustrated 
by a fainting fit in which loss of consciousness follows the heart weakness. 
When the result of haemorrhage, there are drowsiness, giddiness, inability 
to stand, flashes of light, dark spots before the eyes, and noises in the ears; 
the respiration becomes hurried; the skin is cool and covered with sweat; 
the pupils are dilated, there may be vomiting, headache, or delirium, and 
gradually, if the bleeding continues, consciousness is lost and death may 
occur with convulsions. In ordinary syncope the loss of consciousness is 
usually transient and the recumbent posture alone may suffice to restore 
the patient to consciousness. In the more chronic forms of brain anaemia, 
such as result from the gradual impoverishment of the blood, as in pro- 
tracted illness or in starvation, the condition known as irritable weakness 
results. Mental effort is difficult, the slightest irritation is followed by 
undue excitement, the patient complains of giddiness and noises in the 
ears, or there may be hallucinations or delirium. These symptoms are met 
with in an extreme grade as a result of prolonged starvation. 

These symptoms are indistinguishable from those due to the so-called 
cerebral hyperaemia. The quality of the blood is deteriorated and the 
velocity of the blood-flow is diminished, so that the cerebral nutrition is 
interfered with. It is interesting to note that lack of suitable nutrition 
gives rise to phenomena of increased irritability in certain of the cerebral 
centres, at least for a time. 

An interesting set of symptoms, to which the term hydrencephaloid 
was applied by Marshall Hall, occurs in the debility produced by prolonged 
diarrhoea in children. The child is in a semi-comatose condition with the 
eyes open, the pupils contracted, and the fontanelle depressed. In the 
earlier period there may be convulsions. The coma may gradually deepen, 
the pupils become dilated, and there may be strabismus and even retraction 
of the head, symptoms which closely simulate those of basilar meningitis. 



AFFECTIONS OF THE BLOOD-VESSELS. 



997 



3. (Edema of the Brain. 

In the pathology of brain lesions oedema formerly played a role almost 
equal in importance to congestion. It occurs under the following condi- 
tions: In general atrophy of the convolutions, in which case the oedema 
is represented by an increase in the cerebro-spinal fluid and in that of the 
meshes of the pia. In extreme venous dilatation from obstruction, as in 
mitral stenosis or in tumors, there may be a condition of congestive oedema, 
in which, in addition to great filling of the blood-vessels, the substance of 
the brain itself is unusually moist. The most acute oedema is a local pro- 
cess found around tumors and abscesses. An intense infiltration, local or 
general, may occur in Bright's disease, and to it, as Traube suggested, cer- 
tain of the uraemic symptoms may be due. 

The anatomical changes are not unlike those of anaemia. When the 
oedema follows progressive atrophy, the fluid is chiefly within and beneath 
the membranes. The brain substance is anaemic and moist, and has a wet, 
glistening appearance, which is very characteristic. In some instances the 
oedema is more intense and local and the brain substance may look infil- 
trated with fluid. The amount of fluid in the ventricles is usually in- 
creased. 

The symptoms are in great part those of lessened blood-flow, and are 
not well defined. As just stated, some of the cerebral features of uraemia 
may depend upon it. Of late years cases have been reported by Raymond, 
Tenneson, and Dercum, in which unilateral convulsions or paralysis have 
occurred in connection with chronic Bright's disease, and in which the 
condition appeared to be associated with oedema of the brain. The older 
writers laid great stress upon an apoplexia serosa, which may really have 
been a general oedema of the brain. Inasmuch as the instances in which 
oedema of the brain occurs are often those in which there is also intoxication, 
or anaemia, or both, it is probably impossible to say at the bedside definitely 
which of these possible factors is responsible for the symptoms in a given 
case. 

4. Cerebral Hemorrhage. 

The bleeding may come from branches of either of the two great 
groups of cerebral vessels — the basal, comprising the circle of Willis and 
the central arteries passing from it and from the first portion of the cere- 
bral arteries, or the cortical group, the anterior, middle, and the posterior 
cerebral vessels. In a majority of the cases the haemorrhage is from the 
central branches, more particularly from those given off by the middle 
cerebral arteries in the anterior perforated spaces, and which supply the 
corpora striata and internal capsules. One of the largest of these branches 
which passes to the third division of the lenticular nucleus and to the an- 
terior part of the internal capsule, the lenticulo-striate artery of Duret, is so 
frequently involved in haemorrhage that it has been called by Charcot the 
artery of cerebral hemorrhage. Haemorrhages from this and from the len- 
ticulo-thalamic artery include more than GO per cent of all cerebral haemor- 
rhages. The bleeding may be into the substance of the brain, to which 



998 



DISEASES OF THE NERVOUS SYSTEM. 



alone the term cerebral apoplexy is applied, or into the membranes, in which 
case it is termed meningeal haemorrhage; both, however, are usually in- 
cluded under the terms intracranial or cerebral haemorrhage. 

Etiology. — The conditions which produce lesions of the blood-ves- 
sels play a very important part; thus the natural tendency to degeneration 
of the vessels in advanced life makes apoplexy much more common after 
the fiftieth year. It may, however, occur in children under ten. On ac- 
count of the greater liability to arterial disease (associated probably with 
muscular exertion and the abuse of alcohol), men are more subject to cere- 
bral haemorrhage than women. Heredity was formerly thought to be an 
important factor in this affection, and the apoplectic habitus or build is 
still referred to. By this is meant a stout plethoric body of medium size, 
with a short neck. Heredity influences cerebral haemorrhage entirely 
through the arteries, and there are families in which these degenerate early, 
usually in association with renal changes. The secondary hypertrophy of 
the heart brings with it serious dangers, which have already been discussed 
in the section upon arteries. The special factors in inducing arterio- 
sclerosis — the abuse of alcohol, immoderate eating, syphilis, and prolonged 
muscular exertion — are found to be important antecedents in a large num- 
ber of cases of cerebral haemorrhage. Chronic lead poisoning and gout 
also may here be mentioned. 

The endocarditis of rheumatism and other fevers may indirectly lead 
to apoplexy by causing embolism and aneurism of the vessels of the brain. 
Cerebral haemorrhage occurs occasionally in the specific fevers and in pro- 
found alterations of the blood, as in leukaemia and pernicious anaemia. 
The actual exciting cause of the haemorrhage is not evident in the majority 
of cases. The attack may be sudden and without any preliminary symp- 
toms. In other instances violent exertion, particularly straining efforts, or 
the excited action of the heart in emotion may cause a rupture. 

Morbid Anatomy. — The lesions causing apoplexy are almost in- 
variably in the cerebral arteries, in which the following changes may lead 
directly to it: 

(a) The production of miliary aneurisms, rupture of which is the most 
common cause of cerebral haemorrhage. The origin of the miliary aneu- 
risms is disputed. Charcot thought they resulted from changes in the 
advent itia (periarteritis). Others, with Eichler, Ziegler, and Birch-Hirsch- 
feld, find the primary change in the intima. The weight of opinion at 
present, however, is on the side of the view that the media is first degen- 
erated (Roth, Loewenthal). They occur most frequently on the central 
arteries, but also on the smaller branches of the cortical vessels. On sec- 
tion of the brain substance they may be seen as localized, small dark bodies, 
about the size of a pin's head. Sometimes they are seen in numbers upon 
the arteries when carefully withdrawn from the anterior perforated spaces. 
According to Charcot and Bouchard, who have described them, they are 
most frequent in the central ganglia. In apoplexy after the fortieth year if 
sought for they are rarely missed. The actual miliary aneurism, which 
by its rupture has occasioned the haemorrhage, may be difficult to find, 
but i-f one pours water carefully on the area of haemorrhage, or, better 



AFFECTIONS OF THE BLOOD-VESSELS. 



999 



still, submerges the apoplectic mass for a time, it will usually be found 
possible to do so, and even to find the hole in its wall. 

(b) Aneurism of the branches of the circle of Willis. These are by 
no means uncommon, and will be considered subsequently. 

(c) Endarteritis and periarteritis in the cerebral vessels most commonly 
lead to apoplexy by the production of aneurisms, either miliary or coarse. 
There are instances in which the most careful search fails to reveal any- 
thing but diffuse degeneration of the cerebral vessels, particularly of the 
smaller branches; so that we must conclude that spontaneous rupture may 
occur without the previous formation of aneurism. 

(d) Increased permeability of the walls of the vessels may account for 
haemorrhages by diapedesis without actual rupture. Such haemorrhages 
are not uncommon in cases of contracted kidney, grave anaemia, and various 
infections and intoxications. 

The haemorrhage may be meningeal, cerebral, or intraventricular. 

Meningeal haemorrhage may be outside the dura, between this membrane 
and the bone, or between the dura and arachnoid, or between the arach- 
noid and the pia mater. The following are the chief causes of this form 
of haemorrhage: Fracture of the skull, in which case the blood usually 
comes from the lacerated meningeal vessels, sometimes from the torn si- 
nuses. In these cases the blood is usually outside the dura or between it 
and the arachnoid. The next most frequent cause is rupture of aneurisms 
on the larger cerebral vessels. The blood is usually subarachnoid. An 
intracerebral haemorrhage may burst into the meninges. A special form 
of meningeal haemorrhage is found in the new-born, associated with injury 
during birth. And lastly, meningeal haemorrhage may occur in the con- 
stitutional diseases and fevers. The blood may be in a large quantity at 
the base; in cases of ruptured aneurism, particularly, it may extend into 
the cord or upon the cortex. Owing to the greater frequency of the aneu- 
risms in the middle cerebral vessels, the Sylvian fissures are often distended 
with blood. 

Intracerebral haemorrhage is most frequent in the neighborhood of the 
corpus striatum, particularly toward the outer section of the lenticular 
nucleus. The haemorrhage may be small and limited to the lenticular 
body, the thalamus, and the internal capsule, or it may extend into the 
centrum semi-ovale, or burst into the lateral ventricle, or extend to the 
insula. Haemorrhages confined to the white matter — the centrum semi- 
ovale — are rare. Localized bleeding may occur in the crura or in the pons. 
Haemorrhage into the cerebellum is not uncommon, and usually comes 
from the superior cerebellar artery. The extravasation may be limited to 
the substance or rupture into the fourth ventricle. Twice I have known 
sudden death in girls under twenty-five to be due to cerebellar haemorrhage. 

Ventricular Haemorrhage. — This occasionally but rarely is primary, com- 
ing from the vessels of the plexuses or of the walls. More often it is sec- 
ondary, following haemorrhage into the cerebral substance. It is not in- 
frequent in early life and may occur during birth. Of 94 cases collected 
by Edward Sanders, 7 occurred during the first year, and 14 under the 
twentieth year. In the cases which I have se^n in adults it has almost 



1000 



DISEASES OF THE NERVOUS SYSTEM. 



always been caused by rupture of a vessel in the neighborhood of the cau- 
date nucleus. The blood may be found in one ventricle only, but more 
commonly it is in both lateral ventricles, and may pass into the third ven- 
tricle and through the aqueduct of Sylvius into the fourth ventricle, form- 
ing a complete mould in blood of the ventricular system. In these cases 
the clinical picture may be that of " apoplexie foudroyante." 

Subsequent Changes. — The blood gradually changes in color, and ulti- 
mately the haemoglobin is converted into the reddish-brown haematoidin. 
Inflammation occurs about the apoplectic area, limiting and confining it, 
and ultimately a definite wall may be produced, inclosing a cyst with fluid 
contents. In other instances a cyst is not formed, but the connective tissue 
proliferates and leaves a pigmented scar. In meningeal haemorrhage the 
effused blood may be gradually absorbed and leave only a staining of the 
membranes. In other cases, particularly in infants, when the effusion is 
cortical and abundant, there may be localized wasting of the convolutions 
and the production of a cyst in the meninges. Possibly certain of the 
cases of porencephaly are caused in this way. 

Secondary degeneration follows, varying in character according to the 
location of the haemorrhage and the actual damage done by it to nerve cells 
or their medullated axones. Thus, in persons dying some years after a 
cerebral apoplexy which has produced hemiplegia (lesion of the motor area 
in the cortex or of the pyramidal tract leading from it), the degeneration 
may be traced through the cerebral peduncle, the ventral part of the pons, 
the pyramids of the medulla, the fibres of the direct pyramidal tract of 
the cord of the same side, and the fibres of the crossed pyramidal tract on 
the opposite side. After haemorrhages in the middle and inferior frontal 
gyri there follows degeneration of the frontal cerebro-cortico-pontal path, 
going through the anterior limb of the internal capsule and the medial 
portion of the basis pedunculi to the nuclei pontis; also degeneration of the 
fibres connecting the nucleus medialis thalami, and the anterior part of the 
nucleus lateralis thalami with the cortex (Flechsig, v. Monakow). 

When the temporal gyri or their white matter are destroyed by a haem- 
orrhage the lateral segment of the basis pedunculi degenerates (Dejerine). 
Cerebellar haemorrhage, especially if it injure the nucleus dentatus, may 
lead to degeneration of the brachium conjunctivum. 

There may be slow degeneration in the lemniscus medialis, extending as 
far as the nuclei on the opposite side of the medulla oblongata, after haemor- 
rhages in the central gyri, hypothalamic region, or dorsal part of the pons. 
Haemorrhages destroying the occipital cortex, or subcortical haemorrhages 
injuring the optic radiations, occasion slow degeneration (cellulipetal) of the 
radiations from the lateral geniculate body, and after a time cause marked 
atrophy or even disappearance of its ganglion cells. 

Symptoms. — These may be divided into primary, or those connected 
with the onset, and secondary, or those which develop later after the early 
manifestations have passed away. 

Primary Symptoms. — Premonitory indications are rare. As a rule, the 
patient is seized while in full health or about the performance of some 
every-day action, occasionally an action requiring strain or extra exertion. 



AFFECTIONS OF THE BLOOD-VESSELS. 



1001 



Now and then instances are found in which there are sensations of numb- 
ness or tingling or pains in the limbs, or even choreiform movements in the 
muscles of the opposite side, the so-called prehemiplegic chorea. In other 
cases temporary disturbances of vision and of associated movements of the 
eye-muscles have been noted, but none of the prodromata of apoplexy (the 
so-called " warnings ") are characteristic. The onset of the apoplexy, as the 
symptoms of cerebral haemorrhage are usually called, varies greatly. There 
may be sudden loss of consciousness and complete relaxation of the extremi- 
ties. In such instances the name apoplectic stroke is particularly appropriate. 
In other cases the onset is more gradual and the loss of consciousness may 
not occur for a few minutes after the patient has fallen, or after the paraly- 
sis of the limbs is manifest. In the typical apoplectic attack the condition 
is as follows: There is deep unconsciousness; the patient can not be roused. 
The face is injected, sometimes cyanotic, or of an ashen-gray hue. The pu- 
pils vary; usually they are dilated, sometimes unequal, and always, in deep 
coma, inactive. If the haemorrhage be so located that it can irritate the 
nucleus of the third nerve the pupils are contracted (haemorrhages into the 
pons or ventricles). The respirations are slow, noisy, and accompanied 
with stertor. Sometimes the Cheyne-Stokes rhythm may be present. The 
chest movements on the paralyzed side may be restricted, in rare instances 
on the opposite side. The cheeks are often blown out during expiration, 
with spluttering of the lips. The pulse is usually full, slow, and of in- 
creased tension. The temperature may be normal, but is often found sub- 
normal, and, as in a case reported by Bastian, may sink below 95°. In 
cases of basal haemorrhage the temperature, on the other hand, may be high. 
The urine and faeces are usually passed involuntarily. Convulsions are not 
common. It may be difficult to decide whether the condition is apoplexy 
associated with hemiplegia or sudden coma from other causes. An indica- 
tion of hemiplegia may be discovered in the difference in the tonus of the 
muscles on the two sides. If the arm or the leg is lifted, it drops " dead " 
on the affected side, while on the other it falls more slowly. Rigidity also 
may be present. In watching the movements of the facial muscles in the 
stertorous respiration it will be seen that on the paralyzed side the relaxa- 
tion permits the cheek to be blown out in a more marked manner. The 
head and eyes may be turned strongly to one side — conjugate deviation. In 
such an event the turning is toward the side of the haemorrhage. 

In other cases, in which the onset is not so abrupt, the patient may not 
lose consciousness, but in the course of a few hours there is loss of power, 
unconsciousness gradually develops, and deepens into profound coma. This 
is sometimes termed ingravescent apoplexy. The attack may occur during 
sleep. The patient may be found unconscious, or wakes to find that the 
power is lost on one side. Small haemorrhages in the territory of the cen- 
tral arteries may cause hemiplegia without loss of consciousness. 

Usually within forty-eight hours after the onset of an attack, some- 
times within from two to six hours, there is febrile reaction, and more or 
less constitutional disturbance associated with inflammatory changes about 
the haemorrhage and absorption of the blood. The period of inflammatory 
reaction may continue for from one week to two months. The patient may 
G3 



1002 



DISEASES OF THE NERVOUS SYSTEM. 



die in this reaction, or, if consciousness has been regained, there may be 
delirium or recurrence of the coma. At this period the so-called early 
rigidity may develop in the paralyzed limbs. The so-called trophic changes 
may occur, such as sloughing or the formation of vesicles. The most 
serious of these is the sloughing eschar of the lower part of the back, or on 
the paralyzed side, which may appear within forty-eight hours of the onset 
and is usually of grave significance. The congestion at the bases of the 
lungs so common in apoplexy is regarded by some as a trophic change. 

Conjugate Deviation. — In a right hemiplegia the eyes and head may 
be turned to the left side; that is to say, the eyes look toward the cerebral 
lesion. This is almost the rule in the conjugate deviation of the head and 
eyes which occurs early in hemiplegia. When, however, convulsions or 
spasm develop or the state of so-called early rigidity in hemiplegia, the 
conjugate deviation of the head and eyes may be in the opposite direction; 
that is to say, the eyes look away from the lesion and the head is rotated 
toward the convulsed side. This symptom may be associated with cortical 
lesions, particularly, according to some authors, when in the neighbor- 
hood of the supramarginal and angular gyri. It may also occur in a lesion 
of the internal capsule or in the pons, but in the latter situation the con- 
jugate deviation is the reverse of that which occurs in other cases, as the 
patient looks away from the lesion, and in spasm or convulsion looks toward 
the lesion. 

Hemiplegia. — In cases in which consciousness is restored and the pa- 
tient improves, a unilateral paralysis may persist due to the destruc- 
tion of the motor area or the pyramidal tract in any part of its course. 
Hemiplegia is complete when it involves face, arm, and leg, or partial 
when it involves only one or other of these parts. This may be the 
result of a lesion (a) of the motor cortex; (b) of the pyramidal fibres 
in the corona radiata and in the internal capsule; (c) of a lesion in the 
cerebral peduncle; or (d) in the pons Varolii. The situation of the lesions 
and their effects are given in Fig. 10. Haemorrhage is perhaps the most 
common cause, but tumors and spots of softening may also induce it. The 
special details of the hemiplegia may here be considered. The face (except 
in lesions in the lower part of the pons) is involved on the same side as the 
arm and leg. This results from the fact that the facial muscles stand in 
precisely the same relation to the cortical centres as those of the arm and 
leg, the fibres of the upper motor segment of the facial nerve from the 
cortex decussating just as do those of the nerves of the limbs. The facial 
paralysis is partial, involving only the lower portion of the nerve, so that 
the orbicularis oculi and the frontalis muscles are uninvolved. The signs 
of the facial paralysis are usually well marked. There may be a slight diffi- 
culty in elevating the eyebrows or in closing the eye on the paralyzed side, 
or in rare cases the facial paralysis is complete, but the movements may be 
present with emotion, as laughing or crying. The hypoglossal nerve also 
is involved. In consequence, the patient cannot put out the tongue 
straight, but it deviates toward the paralyzed side, inasmuch as the genio- 
hyo-glossus of the sound side is unopposed. With right hemiplegia there 
may be aphasia. Even without marked aphasia difficulty in speaking 
and slowness are common. 



AFFECTIONS OF THE BLOOD-VESSELS. 



1003 




Fig. 10. — Diagram of motor path from right brain. The upper segment is black, the 
lower red. The nuclei of the motor cerebral nerves are shown on the left side ; on 
the right side the cerebral nerves of that side are indicated. A lesion at 1 would 
cause upper segment paralysis in the arm of the opposite side — cerebral mono- 
plegia; at 2, upper segment paralysis of the whole opposite side of the body — 
hemiplegia; at 3 (in the crus), upper segment paralysis of the opposite face, arm and 
leg, and lower segment paralysis of the eye muscles on the same side — crossed paraly- 
sis; at 4 (in the lower part of the pons), upper segment paralysis of the opposite arm 
and leg, and lower segment paralysis of the face and the external rectus on the same 
side — crossed paralysis; at 5, upper segment paralysis of all muscles represented be- 
low lesion, and lower segment paralysis of muscles represented at level of lesion — 
spinal paraplegia ; at 6, lower segment paralysis of muscles localized at seat of lesion • 
— anterior poliomyelitis. (Van Gehuchten, modified.) 



1004 



DISEASES OF THE NERVOUS SYSTEM. 



The arm is, as a rule, more completely paralyzed than the leg. The 
loss of power may be absolute or partial. In severe cases it is at first com- 
plete. In others, when the paralysis in the face and arm is complete 
that of the leg is only partial. The face and arm may alone be paralyzed, 
while the leg escapes. Less commonly the leg is more affected than the 
arm, and the face may be only slightly involved. 

Certain muscles escape in hemiplegia, particularly those associated in 
symmetrical movements, as those of the thorax and abdomen, a fact which 
Broadbent explains by supposing that as the spinal nuclei controlling these 
movements on both sides constantly act together, they may, by means of 
this intimate connection, be stimulated by impulses coming from only one 
side of the brain. The degree of permanent paralysis after a hemiplegic 
attack varies much in different cases. When the restitution is partial, it is 
always, as Wernicke has pointed out, certain groups of muscles which re- 
cover rather than others. Thus in the leg the residual paralysis concerns 
the flexors of the leg and the dorsal flexors of the foot — i. e., the muscles 
which,- according to Ludwig Mann, are active in the second period of walk- 
ing, shortening the leg, and bringing it forward while it swings. The mus- 
cles which lift the body when the foot rests upon the ground, those used in 
the first period of walking, include the extensors of the leg and the plantar 
flexors of the foot. These " lengtheners " of the leg often recover almost 
completely in cases in which the paralysis is due to lesions of the pyramidal 
tract. In the arms the residual paralysis usually affects the muscle groups 
which oppose the thumb, those which rotate the arm outward, and the open- 
ers of the hand. 

As a rule, there is at first no wasting of the paralyzed limbs. 

Crossed ^Hemiplegia. — A paralysis in which there is loss of function in 
a cerebral nerve on one side with loss of power (or of sensation) on the oppo- 
site side of the body is called a crossed or alternate hemiplegia. It is met 
with in lesions, commonly haemorrhage, in the cms, the pons, and the me- 
dulla (Fig. 10, 3 and 4). 

(a) Cms. — The bleeding may extend from vessels supplying the corpus 
striatum, internal capsule, and optic thalamus, or the haemorrhage may be 
primarily in the crus. In the classical case of Weber, on section of the 
lower part of the left crus an oblong clot 15 mm. in length lay just below 
the medial and inferior surface. The characteristic features of a lesion 
in this locality are paralysis of arm, face, and leg of the opposite side, and 
oculo-motor paralysis of the same side — the syndrome of Weber. Sensory 
changes have also been present. Haemorrhage into the tegmentum is 
not necessarily associated with hemiplegia, but there may be incomplete 
paralysis of the oculo-motor nerve, with disturbance of sensation and ataxia 
on the opposite side of the body. The optic tract or the lateral geniculate 
body lying on the lateral side of the crus may be compressed, in which 
event there will be hemianopsia. 

(b) Pons and Medulla. — Lesions may involve the pyramidal tract and 
one or more of the cerebral nerves. If at the lower aspect of the pons, the 
facial nerve may be involved, causing paralysis of the face on the same 
side and hemiplegia on the opposite side. The fifth nerve may be involved, 



AFFECTIONS OF THE BLOOD-VESSELS. 



1005 



with the fillet (the sensory tract), causing loss of sensation in the area of 
■distribution of the fifth on the same side as the lesion and loss of sensation 
on the opposite side of the body. 

Sensory Disturbances resulting from Cerebral Haemorrhage. — These are 
variable. Hemianesthesia may coexist with hemiplegia, but in many in- 
stances there is only slight numbing of sensation. When the hemianes- 
thesia is marked, it is usually the result of a lesion in the internal capsule 
involving the retrolenticular portion of the posterior limb. In C. L. 
Dana's study of sensory localization he found that anaesthesia of organic 
cortical origin was always limited or more pronounced in certain parts, as 
the face, arm, or leg, and was generally incomplete. Total anaesthesia was 
•either of functional or subcortical origin. Marked anaesthesia was much 
more common in softening than in haemorrhage. Complete hemianaes- 
thesia is certainly rare in haemorrhage. Disturbance of the special senses 
is not common. Hemianopia may exist on the same side as the paralysis, 
and there may be diminution in the acuteness of the senses of hearing, 
taste, and smell. Growers thinks that homonymous hemianopia of the 
halves of the visual fields opposite to the lesion is very frequent shortly 
after the onset, though often overlooked. 

Psychic disturbances, variable in nature and degree, may result from 
cerebral haemorrhage. 

The Reflexes in Apoplectic Cases. — During the apoplectic coma all the 
reflexes are abolished, but immediately on recovery of consciousness they 
return, first on the non-hemiplegic side, later, sometimes only after weeks, 
on the paralyzed side. As to the time of return, especially of the patellar 
reflexes, marked differences are observable in individual cases. The deep 
reflexes later are increased on the paralyzed side, and ankle clonus may be 
present. The plantar and other superficial reflexes are usually diminished. 
The sphincters are not affected. 

The course of the disease depends upon the situation and extent of the 
lesion. If slight, the hemiplegia may disappear completely within a few 
days or a few weeks. In severe cases the rule is that the leg gradually re- 
covers before the arm, and the muscles of the shoulder girdle and upper 
a,rm before those of the forearm and hand. The face may recover quickly. 

Except in the very slight lesions, in which the hemiplegia is transient, 
changes take place which may be grouped as 

Secondary Symptoms. — These correspond to the chronic stage. In a 
case in which little or no improvement takes place within eight or ten 
weeks, it will be found that the paralyzed limbs undergo certain changes. 
The leg, as a rule, recovers enough power to enable the patient to get 
about, although the foot is dragged. Occasionally a recurrence of severe 
symptoms is seen, even without a new hemorrhage having taken place. In 
both arm and leg the condition of secondary contraction or late rigidity comes 
•on and is always most marked in the upper extremity. The arm becomes 
permanently flexed at the elbow and resists all attempts at extension. The 
wrist is flexed upon the forearm and the fingers upon the hand. The posi- 
tion of the arm and hand is very characteristic. There is frequently, as 
the contractures develop, a great deal of pain. In the leg the contracture is 



1006 



DISEASES OF THE NERVOUS SYSTEM. 



rarely so extreme. The loss of power is most marked in the muscles of 
the foot, and to prevent the toes from dragging, the knee in walking 
is much flexed, or more commonly the foot is swung round in a half- 
circle. 

The reflexes are at this stage greatly increased. These contractures are 
permanent and incurable, and are associated with a secondary descending 
sclerosis of the motor path. There are instances, however, in which rigid- 
ity and contracture do not occur, but the arm remains flaccid, the leg hav- 
ing regained its power. This MmipUgie flasque of Bouchard is found most 
commonly in children. Among other secondary changes in late hemiplegia 
may be mentioned the following: Tremor of the affected limbs, post-para- 
lytic chorea, the mobile spasm known as athetosis, arthropathies in the 
joints of the affected side, and muscular atrophy. Athetosis and post- 
hemiplegic chorea will be considered in the hemiplegia of children. The 
cool surface and thin glossy skin of a hemiplegic limb are familiar to all. 
A word may here be said upon the subject of muscular atrophy of cerebral 
origin. 

As a rule, atrophy is not a marked feature in hemiplegia, but in some 
instances it does develop. It has been thought to be due in some cases to 
secondary alterations in the gray matter of the ventral horns, as in a case 
reported by Charcot. Kecently, however, attention has been called by 
Senator, Quincke, and others to the fact that atrophy may follow as a direct 
result of the cerebral lesion, the ventral horns remaining intact. In 
Quincke's case, atrophy of the arm followed the development of a glioma 
in the anterior central convolution. The gray matter of the ventral horns 
was normal. These atrophies are most common in cortical lesions involv- 
ing the domain of the third main branch of the Sylvian artery, and in cen- 
tral lesions involving the lenticulo-thalamic region. Their explanation is 
not clear. The wasting of cerebral origin, which occurs most frequently in 
children, and leads to hemiatrophy of the muscles along with stunted growth 
of the bones and joints, is to be sharply separated from the hemiatrophy of 
the muscles of the adult following within a relatively short time upon the 
hemiplegia. 

Diagnosis. — There are three groups of cases which offer increasing 
difficulty in recognition. 

(1) Cases in which the onset is gradual, a day or two elapsing before 
the paralysis is fully developed and consciousness completely lost, are readily 
recognized, though it may be difficult to determine whether the lesion is 
due to thrombosis or to haemorrhage. 

(2) In the sudden apoplectic stroke in which the patient rapidly loses 
consciousness, the difficulty in diagnosis may be still greater, particularly 
if the patient is in deep coma when first seen. 

The first point to be decided is the existence of hemiplegia. This may 
be difficult, although, as a rule, even in deep coma the limbs on the para- 
lyzed side are more flaccid and drop instantly when lifted; whereas, on the 
non-paralyzed side the muscles retain some degree of tonus. The reflexes 
may be decreased or lost on the affected side and there may be conjugate de- 
viation of the head and eyes. Rigidity in the limbs of one side is in favor of a 



AFFECTIONS OF THE BLOOD-VESSELS. 



1007 



hemiplegic lesion. It is practically impossible in a majority of these cases 
to say whether the lesion is due to haemorrhage, embolism, or thrombosis. 

(3) Large haemorrhage into the ventricles or into the pons may pro- 
duce sudden loss of consciousness with complete relaxation, so that the 
condition may simulate coma from uraemia, diabetes, alcoholism, opium 
poisoning, or epilepsy. 

The previous history and the mode of onset may give valuable informa- 
tion. In epilepsy, convulsions have preceded the coma; in alcoholism, there 
is a history of constant drinking, while in opium poisoning the coma de- 
velops more gradually; but in many instances the difficulty is practically 
very great, and on more than one occasion I have seen mortifying post- 
mortem disclosures under these circumstances. With diabetic coma the 
breath often smells of acetone. In ventricular haemorrhage the coma is 
sudden and develops rapidly. The hemiplegic symptoms may be transient, 
quickly giving place to complete relaxation. Convulsions occur in many 
cases, and may be the very symptom to lead astray — as in a case of ven- 
tricular haemorrhage which occurred in a puerperal patient, in whom, natu- 
rally enough, the condition was thought to be uraemic. Eigidity is often 
present. In haemorrhage into the pons convulsions are frequent. The 
pupils may be strongly contracted,' conjugate deviation may occur, and the 
temperature is apt to rise rapidly. The contraction of the pupils in pontine 
haemorrhage naturally suggests opium poisoning. The difference in tem- 
perature in the two conditions is a valuable diagnostic point. The apoplecti- 
form seizures of general paresis have usually been preceded by abnormal 
mental symptoms, and the associated hemiplegia is seldom permanent. 

It may be impossible at first to give a definite diagnosis. In admissions 
to hospitals or in emergency cases the physician should be particularly care- 
ful about the following points: The examination of the head for injury 
or fracture; the urine should be tested for albumin, examined for sugar, 
and studied microscopically; a careful examination should be made of the 
limbs with reference to their degree of relaxation or the presence of rigidity, 
and the condition of the reflexes; the state of the pupils should be noted 
and the temperature taken. The odor of the breath (alcohol, acetone, 
chloroform, etc.) should be remarked. The most serious mistakes are made 
in the case of patients who are drunk at the time of the attack, a combina- 
tion by no means uncommon in the class of patients admitted to hospital. 
Under these circumstances the case may erroneously be looked upon as one 
of alcoholic coma. It is best to regard each case as serious and to bear in 
mind that this is a condition in which, above all others, mistakes are 
common. 

Prognosis. — From cortical haemorrhage, unless very extensive, the 
recovery may be complete without a trace of contracture. This is more 
common when the haemorrhage follows injury than when it results from 
disease of the arteries. Infantile meningeal haemorrhage, on the other 
hand, is a condition which may produce idiocy or spastic diplegia. 

Large haemorrhages into the corona radiata, and especially those which 
rupture into the ventricles, rapidly prove fatal. 

The hemiplegia which follows lesions of the internal capsule, the result 



1008 



DISEASES OF THE NERVOUS SYSTEM. 



of rupture of the lenticulo-striate artery, is usually persistent and followed 
by contracture. When the retro-lenticular fibres of the internal capsule 
are involved there may be hemianesthesia, and later, especially if the thala- 
mus be implicated, hemichorea or athetosis. In any case of cerebral apo- 
plexy the following symptoms are of grave omen: persistence or deepening 
of the coma during the second and third day; rapid rise in temperature 
within the first forty-eight hours after the initial fall. In the reaction 
which takes place on the second or third day, the temperature usually rises, 
and its gradual fall on the third or fourth day with return of consciousness 
is a favorable indication. The rapid formation of bed-sores, particularly 
the malignant decubitus of Charcot, is a fatal indication. The occurrence 
of albumin and sugar, if abundant, in the urine is an unfavorable symptom. 

When consciousness returns and the patient is improving, the question 
is anxiously asked as to the paralysis. The extent of this cannot be deter- 
mined for some weeks. With slight lesions it may pass off entirely. If 
persistent at the end of a month some grade of permanent palsy is certain 
to remain, and gradually the late rigidity supervenes. 

5. Embolism and Thrombosis (Cerebral Softening). 

(a) Embolism. — The embolus usually enters the carotid, rarely the verte- 
bral artery. In the great majority of cases it comes from the left heart and 
is either a vegetation of a fresh endocarditis or, more commonly, of a recur- 
ring endocarditis, or from the segments involved in an ulcerative process. 
Less often the embolus is a portion of a clot which has formed in the au- 
ricular appendix. Portions of clot from an aneurism, thrombi from athe- 
roma of the aorta, or from the territory of the pulmonary veins, may also 
cause blocking of the branches of the circle of Willis. In the puerperal 
condition cerebral embolism is not infrequent. It may occur in women 
with heart-disease, but in other instances the heart is uninvolved, and the 
condition has been thought to be associated with the development of heart- 
clots, owing to increased coagulability of the blood, A majority of cases 
of embolism occur in heart-disease, 89 per cent (Saveliew). Cases are rare 
in the acute endocarditis of rheumatism, chorea, and febrile conditions. It 
is much more common in the secondary recurring endocarditis which at- 
tacks old sclerotic valves. The embolus most frequently passes to the left 
middle cerebral artery, as it enters the left carotid oftener than the right 
because of the more direct course of the blood in the former. The poste- 
rior cerebral and the vertebral are less often affected. A large plug may 
lodge at the bifurcation of the basilar. Embolism of the cerebral vessels is 
rare. 

Embolism occurs more frequently in women, owing, no doubt, to the 
greater frequency of mitral stenosis. Contrary to this general statement, 
Newton Pitt's statistics of 79 cases at Guy's Hospital indicate, however, 
that males are more frequently affected; for in this series there were 44 
males and 35 females. Saveliew gives 54 per cent in women. 

(b) Thrombosis. — Clotting of blood in the cerebral vessels occurs (1) 
about an embolus, (2) as the result of a lesion of the arterial wall (either 



AFFECTIONS OF THE BLOOD-VESSELS. 



1009 



endarteritis with or without atheroma or, particularly, the syphilitic arteri- 
tis), (3) in aneurisms both coarse and miliary, and (4) very rarely as a direct 
result of abnormal conditions of the blood. Thrombosis occasionally fol- 
lows ligation of the carotid artery. The thrombosis is most common in the 
middle cerebral and in the basilar arteries. According to Kolisko, soften- 
ing of limited areas, sufficient to induce hemiplegia, may be caused by sud- 
den collapse of certain cerebral arteries from cardiac weakness. 

Anatomical Changes. — Degeneration and softening of the territory sup- 
plied by the vessels is the ultimate result in both embolism and thrombosis. 
Blocking in a terminal artery may be followed by infarction, in which the 
territory may either be deeply infiltrated with blood (haemorrhagic infarc- 
tion) or be simply pale, swollen, and necrotic (anaemic infarction). Grad- 
ually the process of softening proceeds, the tissue is infiltrated with serum 
and is moist, the nerve fibres degenerate and become fatty. The neuroglia 
is swollen and cedematous. The color of the softened area depends upon 
the amount of blood. The haemoglobin undergoes gradual transformation, 
and the early red color may give place to yellow. Formerly much stress 
was laid upon the difference between red, yellow, and white softening. The 
red and yellow are seen chiefly on the cortex. Sometimes the red softening 
is particularly marked in cases of embolism and in the neighborhood of 
tumors. The gray matter shows many punctiform haemorrhages — capillary 
apoplexy. There is a variety of yellow softening — the plaques jaunes — 
common in elderly persons, which occurs in the gray matter of the convolu- 
tions. The spots are from 1 to 2 cm. in diameter, sometimes are angular in 
shape, the edges cleanly cut, and the softened area is represented by either 
a turbid, yellow material, or in some instances there is a space crossed by 
fine trabecular, in the meshes of which there is fluid. White softening- 
occurs most frequently in the white matter, and is seen best about tumors 
and abscesses. Inflammatory changes are common in and about the soft- 
ened areas. When the embolus is derived from an infected focus, as in 
ulcerative endocarditis, suppuration may follow. The final changes vary 
very much. The degenerated and dead tissue elements are gradually but 
slowly removed, and if the region is small may be replaced by a growth of 
connective tissue and the formation of a scar. If large, the resorption 
results in the formation of a cyst. It is surprising for how long an area 
of softening may persist without much change. 

The position and extent of the softening depend upon the obstructed 
artery. An embolus which blocks the middle cerebral at its origin involves 
not only the arteries to the anterior perforated space, but also the cortical 
branches, and in such a case there is softening in the neighborhood of the 
corpus striatum, as well as in part of the region supplied by the cortical 
vessels. The freedom of anastomosis between these branches varies a good 
deal. Thus, there are instances of embolism of the middle cerebral artery 
in which the softening has only involved the territory of the central 
branches, in which case blood has reached the cortex through the anterior 
and posterior cerebrals. When the middle cerebral is blocked (as is perhaps 
oftenest the case) beyond the point of origin of the central arteries, one or 
other of its branches is usually most involved. The embolus may lodge 



1010 



DISEASES OF THE NERVOUS SYSTEM. 



in the vessel passing to the third frontal convolution, or in the artery of 
the ascending frontal or ascending parietal; or it may lodge in the branch 
passing to the supramarginal and angular gyri, or it may enter the lowest 
branch which is distributed to the upper convolutions of the temporal lobe. 
These are practically terminal arteries, and instances frequently occur of 
softening limited to a part, at any rate, of the territory supplied by them. 
Some of the most accurate focalizing lesions are produced in this way. 

Symptoms. — Extensive thrombotic softening may exist without any 
symptoms. It is not uncommon in the post-mortem examination of the 
bodies of elderly persons to find the plaques jaunes scattered over the con- 
volutions. So, too, softening may take place in the " silent " regions, as 
they are termed, without exciting any symptoms. When the central or 
cortical branches of the middle cerebral arteries are involved the symp- 
toms are similar to those of hemorrhage from the same arteries. Permanent 
or transient hemiplegia results. When the central arteries are involved 
the softening in the internal capsule is commonly followed by permanent 
hemiplegia. There are certain peculiarities associated with embolism and 
with thrombosis respectively. 

In embolism the patient is usually the subject of heart-trouble, or there 
exist some of the conditions already mentioned. The onset is sudden, 
without premonitory symptoms. When the embolism blocks the left middle 
cerebral artery the hemiplegia is usually associated with aphasia. In throm- 
bosis, on the other hand, the onset is more gradual; the patient has pre- 
viously complained of headache, vertigo, tingling in the fingers; the speech 
may have been embarrassed for some days; the patient has had loss of 
memory or is incoherent, or paralysis begins at one part, as the hand, and 
extends slowly, and the hemiplegia may be incomplete or variable. Abrupt 
loss of consciousness is much less common, and when the lesion is small 
consciousness is retained. Thus, in thrombosis due to syphilitic disease, 
the hemiplegia m£y come on gradually without the slightest disturbance 
of consciousness. 

The hemiplegia following thrombosis or embolism has practically the 
characteristics, both primary and secondary, described under hemorrhage. 

The following may be the effects of blocking the different vessels: 
(a) Vertebral. — The left branch is more frequently plugged. The effects 
are involvement of the nuclei in the medulla and symptoms of acute bulbar 
paralysis. It rarely occurs alone; more commonly with 

(b) Blocking of the basilar artery. When this is entirely occluded, there 
may be bilateral paralysis from involvement of both motor paths. Bulbar 
symptoms may be present; rigidity or spasm may occur. The temperature 
may rise rapidly. The symptoms, in fact, are those of apoplexy of the pons. 

(c) The posterior cerebral supplies the occipital lobe on its medial sur- 
face and the greater part of the temporo-sphenoidal lobe. If the main stem 
be thrombosed there is hemianopia with sensory aphasia. Localized areas of 
softening may exist without symptoms. Blocking of the main occipital 
branch (arteria occipitalis of Duret), or of the arteria calcarina, passing 
to the cuneus may be followed by hemianopia. Hemianesthesia may re- 
sult from involvement of the posterior part of the internal capsule. Not 



AFFECTIONS OF THE BLOOD-VESSELS. 



1011 



infrequently symmetrical thrombosis of the occipital arteries of the two 
sides occurs, as in Forster's well-known case. Still more frequent is the 
occurrence of thrombosis of a branch of the posterior cerebral of one hemi- 
sphere and a branch of the middle cerebral of the other (von Monakow). 
It is in such cases that the most pronounced instances of apraxia are met 
with. 

(d) Internal Carotid. — The symptoms are variable. As is well known, 
the vessel is in a majority of cases ligated without risk. In other instances 
transient hemiplegia follows; in others again the hemiplegia is permanent. 
These variations depend on the anastomoses in the circle of Willis. If 
these are large and free, no paralysis follows, but in cases in which the pos- 
terior communicating and the anterior communicating vessels are small or 
absent, the paralysis may persist. In No. 7 of my Elwyn series of cases of 
infantile hemiplegia, the woman, aged twenty-four, when six years old, had 
the right carotid ligated for abscess following scarlet fever, with the result 
of permanent hemiplegia. Blocking of the internal carotid within the 
skull by thrombosis or embolism is followed by hemiplegia, coma, and usu- 
ally- death. The clot is rarely confined to the carotid itself, but spreads 
into its branches and may involve the ophthalmic artery. 

(e) Middle Cerebral. — This is the vessel most commonly involved, and, 
as already mentioned, if plugged before the central arteries are given off, 
permanent hemiplegia usually follows from softening of the internal cap- 
sule. Blocking of the branches beyond this point may be followed by 
hemiplegia, which is more likely to be transient, involves chiefly the arm 
and face, and if on the left side is associated with aphasia. The individual 
branches passing to the inferior frontal (producing typical motor aphasia 
if the disease be on the left side), anterior and posterior central gyri (usually 
causing total hemiplegia), to the supramarginal and angular gyri (giving 
rise, if the thrombosis be on the left side, probably without exception to 
the so-called visual aphasia (alexia), usually also to right-sided hemi- 
anopsia), or to the temporal gyri (in which event with left-sided thrombosis 
word-deafness results) may be plugged. 

(/) Anterior Cerebral. — No symptoms may follow, and even when the 
branches which supply the paracental lobule and the top of the ascending 
convolutions are plugged the branches from the middle cerebral are usually 
able to effect a collateral circulation in these parts. Monoplegia of the leg 
may, however, result. Hebetude and dulness of intellect may occur with 
obstruction of the vessel. 

There is unquestionably greater freedom of communication in the cor- 
tical branches of the different arteries than is usually admitted, although 
it is not possible, for example, to inject the posterior cerebral through the 
middle cerebral, or the middle cerebral from the anterior; but the absence 
of softening in some instances in which smaller branches are blocked shows 
how complete may be the compensation, probably by way of the capillaries. 
The dilatation of the collateral brandies may take place very rapidly; thus 
a patient with chronic nephritis died about twenty-four hours after the 
hemiplegic attack. There were 1 recent vegetations on the mitral valve and 
an embolus in the right middle cerebral artery just beyond the first two 



1012 



DISEASES OF THE NERVOUS SYSTEM. 



branches. The central portion of the hemisphere was swollen and cedema- 
tous. The right anterior cerebral was greatly dilated, and by measurement 
its diameter was found to be nearly three times that of the left. 

Treatment of Cerebral Haemorrhage and of Softening. 

— The patient should be placed on his back, with the head high, the neck 
free, kept absolutely quiet, and measures immediately taken to reduce the 
arterial pressure. Of these the most rapid and satisfactory is venesection, 
which should be practised whenever the arterial tension is much increased. 
With a small pulse of low tension and signs of cardiac weakness it is contra- 
indicated. The chief difficulty is in determining whether the apoplexy is 
really due to haemorrhage, or to thrombosis or embolism, since in the latter 
group of cases bleeding probably does harm. As a rule, however, in middle- 
aged men with arterio-sclerosis, an accentuated aortic second sound, and 
hypertrophy of the left ventricle, bleeding is indicated. Horsley and Spen- 
cer have recently, on experimental grounds, recommended the practice, 
formerly employed empirically, of compression of the carotid, particularly 
in the ingravescent form; or even, in suitable cases, passing a ligature round 
the vessel. An ice-bag may be placed on the head and hot bottles to the 
feet. The bowels should be freely opened, either by calomel, or croton 
oil placed on the tongue. Counter-irritation to the neck or to the feet is 
not necessary. Catheterization of the bladder may be necessary, especially 
if the patient remain long unconscious. When dyspnoea, stertor, and signs 
of mechanical obstruction are present, the patient should be turned on the 
side, as recommended by Bowles. This procedure also lessens the liability 
to congestion of the lungs. 

Special care should be taken to avoid bed-sores; and if bottles are used 
to the feet, they should not be too hot, since blisters may be readily caused 
by much lower temperature than in health. In the fever of reaction, aconite 
may be indicated, but should be cautiously used. Stimulants are not neces- 
sary, unless the pulse becomes feeble and signs of collapse supervene. No 
digitalis is to be given. During recovery the patient should be still kept 
entirely at rest, even in the mildest cases remaining in bed for at least four- 
teen days. The ice-bag should still be kept at the head. The diet should 
be light and no medicine other than some placebo should be administered, 
at least during the first month after the haemorrhage. Attention should 
be paid to the position occupied by the paralyzed limb or limbs, which if 
swollen may be wrapped in cotton batting or flannel. 

The treatment of softening from thrombosis or embolism is very un- 
satisfactory. Venesection is not indicated, as it lowers the tension and 
rather promotes clotting. If, as is often the case, the heart's action is feeble 
and irregular, stimulants and small doses of digitalis may be given with, 
if necessary, ether or ammonia. The bowels should be kept open, but it is 
not well to purge actively, as in haemorrhage. 

In the thrombosis which follows syphilitic disease of the arteries, and 
which is met with most frequently in men between twenty and forty (in 
whom the hemiplegia often sets in without loss of consciousness), the iodide 
of potassium should be freely used, giving from 20 to 30 grains three times 
a day, or, if necessary, larger doses. If the syphilis has been recent, mer- 



AFFECTIONS OF THE BLOOD-VESSELS. 



1013 



curials by inunction are also indicated. Practically these are the only cases 
of hemiplegia in which we see satisfactory results from treatment. 

Operative treatment has been suggested, and when the diagnosis of sub- 
dural haemorrhage can be made it is justifiable. An attempt to reach a 
central haemorrhage in the neighborhood of the internal capsule would only 
increase the damage to the brain substance. Very little can be done for 
the hemiplegia which remains. The damage is too often irreparable and 
permanent, and it is very improbable that iodide of potassium, or any 
other remedy, hastens in the slightest degree Nature's dealing with the 
blood-clot. 

The paralyzed limbs may be gently rubbed once or twice a day, and 
this should be systematically carried out, in order to maintain the nutri- 
tion of the muscles and to prevent, if possible, contractures. The massage 
should not, however, be begun until at least ten days after the attack. The 
rubbing should be toward the body, and should not be continued for more 
than fifteen minutes at a time. After the lapse of a fortnight, or in severe 
cases a month, the muscles may be stimulated by the faradic current; faradic 
stimulation alternating with massage, especially if applied to the antagonists 
of the muscles which ordinarily undergo contracture, is of very great service, 
even in cases where there can be but little hope of any return of voluntary 
movement. When contractures develop, electricity properly applied at 
intervals may still be of some benefit along with the passive movements and 
frictions. 

In a case of complete hemiplegia, the friends should at the outset be 
frankly told that the chances of full recovery are slight. Power is usually 
restored in the leg sufficient to enable the patient to get about, but in the 
majority of instances the finer movements of the hand are permanently lost. 
The general health should be looked after, the bowels regulated, and the 
secretions of the skin and kidneys kept active. In permanent hemiplegia 
in persons above the middle period of life, more or less mental weakness is 
apt to follow the attack, and the patient may become irritable and emo- 
tional. 

And, lastly, when hemiplegia has persisted for more than three months 
and contractures have developed, it is the duty of the physician to explain 
to the patient, or to his friends, that the condition is past relief, that medi- 
cines and electricity will do no good, and that there is no possible hope of 
cure. 

6. Aneurism of the Cerebral Arteries. 

Miliary aneurisms are not included, but reference is made only to aneu- 
rism of the larger branches. The condition is not uncommon. There were 
12 instances in my first 800 autopsies in Montreal.* This is a considerably 
larger proportion than in Newton Pitt's collection from Guy's Hospital, 
19 times in 9,000 inspections. 

Etiology. — Males are more frequently affected than females. Of my 
12 cases 7 were males. The disease is most common at the middle period 



* Canada Medical and Surgical Journal, vol. xiv. 



1014 



DISEASES OF THE NERVOUS SYSTEM. 



of life. One of my cases was a lad of six. Pitt describes one at the same 
age. The chief causes are (a) endarteritis, either simple or syphilitic, which 
leads to weakness of the wall and dilatation; and (&) embolism. As pointed 
out by Church, these aneurisms are often found with endocarditis. Pitt, 
in his recent study of the subject, concludes that it is exceptional to find 
cerebral aneurism unassociated with fungating endocarditis. The em- 
bolus disappears, and dilatation follows the secondary inflammatory changes 
in the coats of the vessel. 

Morbid Anatomy. — The middle cerebral branches are most fre- 
quently involved. In my 12 cases the distribution on the arteries was as 
follows: Internal carotid, 1; middle cerebral, 5; basilar, 3; anterior com- 
municating, 3. Except in one case they were saccular and communicated 
with the lumen of the vessel by an orifice smaller than the circumference 
of the sac. In the 154 cases which make up the statistics of Lebert, 
Durand, and Bartholow the middle cerebral was involved in 44, the basilar 
in 41, internal carotid in 23, anterior cerebral in 14, posterior communi- 
cating in 8, anterior communicating in 8, Vertebral in 7, posterior cere- 
bral in 6, inferior cerebellar in 3 (Gowers). The size of the aneurism 
varies from that of a pea to that of a walnut. The haemorrhage may be 
entirely meningeal with very slight laceration of the brain substance, but 
the bleeding may be, as Coats has shown, entirely within the substance. 

Symptoms. — The aneurism may attain considerable size and cause 
no symptoms. In a majority of the cases the first intimation is the rupture 
and the fatal apoplexy. Distinct symptoms are most frequently caused by 
aneurism of the internal carotid, which may compress the optic nerve or the 
commissure, causing neuritis or paralysis of the third nerve. A murmur 
may be audible on auscultation of the skull. Aneurism in this situation 
may give rise to irritative and pressure symptoms at the base of the brain 
or to hemianopsia. In the remarkable^ case reported by Weir Mitchell and 
Dercum an aneurism compressed the chiasma and produced bilateral tem- 
poral hemianopsia. 

Aneurism of the vertebral or of the basilar may involve the nerves from 
the fifth to the twelfth. A large sac at the termination of the basilar may 
compress the third nerves or the crura. 

The diagnosis is, as a rule, impossible. The larger sacs produce the 
symptoms of tumor, and their rupture is usually fatal. 

7. Endarteritis. 

In no group of vessels do we more frequently see chronic degenera- 
tive changes than in those of the circle of Willis. The condition occurs as: 

(a) Arteriosclerosis, producing localized or diffused thickening of the 
intima with the formation of atheromatous patches or areas of calcification. 
In the later stages, as seen in elderly people, the arteries of the circle of 
Willis may be dilated, stiff, or almost universally calcified. 

(b) Syphilitic Endarteritis. — As already mentioned under the section 
of syphilis, gummatous endarteritis is specially prone to attack the cere- 
bral vessels. It has in itself no specific characters — that is to say, it is im- 



AFFECTIONS OF THE BLOOD-VESSELS. 



1015 



possible in given sections to pick out an endarteritis syphilitica from an 
ordinary endarteritis obliterans. On the other hand, as already stated, the 
nodular periarteritis is never seen except in syphilis. 

8. Thrombosis of the Cerebral Sinuses and Veins. 

The condition may be primary or secondary. Lebert (1854) and Ton- 
nele were among the first to recognize the condition clinically. 

Primary thrombosis of the sinuses and veins is rare. It occurs (a) in 
children, particularly during the first six months of life, usually in con- 
nection with diarrhoea. It has, in my experience, been a rare condition. 
I have never seen an example of spontaneous thrombosis of the sinuses in 
a child, and only two instances, both in connection with meningitis, in 
which the cortical veins contained clots. Gowers believes that it is of fre- 
quent occurrence, and that thrombosis of the veins is not an uncommon 
cause of infantile hemiplegia. 

(b) In connection with chlorosis and anaemia, the so-called autochthonous 
sinus-thrombosis. Of 82 cases of thrombosis in chlorosis, 78 were in the 
veins and 32 in the cerebral sinuses. The longitudinal sinus is most fre- 
quently involved. The thrombosis is usually associated with venous 
thromboses in other parts of the body, and the patients die, as a rule, 
in from one to three weeks, but both Eristowe and Buzzard report re- 
coveries. 

(c) In the terminal stages of cancer, phthisis, and other chronic dis- 
eases thrombosis may gradually occur in the sinuses and cortical veins. To 
the coagulum developing in these conditions the term marantic thrombus 
is applied. 

Secondary thrombosis is much more frequent and follows extension of 
inflammation from contiguous parts to the sinus wall. The common causes 
are disease of the internal ear, fracture, compression of the sinuses by 
tumor, or suppurative disease outside the skull, particularly erysipelas, car- 
buncle, and parotitis. In secondary cases the lateral sinus is most frequently 
involved. Of 57 fatal cases in which ear-disease caused death with cerebral 
lesions, there were 22 in which thrombosis existed in the lateral sinuses 
(Pitt). Tuberculous caries of the temporal bone is often directly responsible. 
The thrombus may be small, or may fill the entire sinus and extend into 
the internal jugular vein. In more than one half of these instances the 
thrombus was suppurating. The disease spreads directly from the necrosis 
on the posterior wall of the tympanum. According to Voltolini, the in- 
flammation extends by way of the petroso-mastoid canal. It is not so com- 
mon in disease of the mastoid cells. 

Symptoms. — Primary thrombosis of the longitudinal sinus may occur 
without exciting symptoms and is found accidentally at the post mortem. 
There may be mental dulness with headache. Convulsions and vomiting 
may occur. In other instances there is nothing distinctive. In a patient 
who died under my care, at the Philadelphia Hospital, of phthisis, there 
was a gradual torpor, deepening to coma, without convulsions, localizing 
symptoms, or optic neuritis. The condition was thought to be due to a 



1016 



DISEASES OF THE NERVOUS SYSTEM. 



terminal meningitis. In the chlorosis cases the head symptoms have, as a 
rule, been marked. Ball's patient was dull and stupid, had vomiting, 
dilatation of the pupils, and double choked disks. Slight paresis of the 
left side occurred. An interesting feature in this case was the develop- 
ment of swelling of the left leg. In the cases reported by Andrews, Church, 
Tuckwell, Isambard Owen, and Wilks the patients had headache, vomit- 
ing, and delirium. Paralysis was not present. In Douglas Powell's case, 
with similar symptoms, there was loss of power on the left side. Bristowe 
reports a case of great interest in an anaemic girl of nineteen, who had con- 
vulsions, drowsiness, and vomiting. Tenderness and swelling developed 
in the position of the right internal jugular vein, and a few clays later on 
the opposite side. The diagnosis was rendered definite by the occurrence 
of phlebitis in the veins of the right leg. The patient recovered. 

The onset of such symptoms as have been mentioned in an anaemic or 
chlorotic girl should lead to the suspicion of cerebral thrombosis. In in- 
fants the diagnosis can rarely be made. Involvement of the cavernous sinus 
may cause oedema about the eyelids or prominence of the eyes. 

In the secondary tlirombi the symptoms are commonly those of septi- 
caemia. For instance, in over 70 per cent of Pitt's cases the mode of death 
was by pulmonary pyaemia. This author draws the following important 
conclusions: (1) The disease spreads oftener from the posterior wall of 
the middle ear than from the mastoid cells. (2) The otorrhcea is gener- 
ally of some standing, but not always. (3) The onset is sudden, the chief 
symptoms being pyrexia, rigors, pains in the occipital region and in the 
neck, associated with a septicaemic condition. (4) Well-marked optic neu- 
ritis may be present. (5) The appearance of acute local pulmonary mis- 
chief or of distant suppuration is almost conclusive of thrombosis. (6) 
The average duration is about three weeks, and death is generally from 
pulmonary pyaemia. The chief points in the diagnosis may be gathered 
from these statements. 

Pitt records an interesting case of recovery in a boy of ten, who had 
otorrhcea for years and was admitted with fever, earache, tenderness, and 
oedema. A week later he had a rigor, and optic neuritis developed on the 
right side. The mastoid was explored unsuccessfully. The fever and 
chills persisting, two days later the lateral sinus was explored. A mass of 
foul clot was removed and the jugular vein was tied, after which the boy 
made a satisfactory recovery. 

According to Griesinger there is often associated with thrombosis of 
the lateral sinus venous stasis and painful oedema behind the ear and in the 
neck. The external jugular vein on the diseased side may be less dis- 
tended than on the opposite side, since owing to the thrombus in the lateral 
sinus the internal jugular vein is less full than on the normal side, and the 
blood from the external jugular can flow more easily into it (Gerhardt). 

Treatment. — In marantic individuals roborants and stimulants are in- 
dicated. The position assumed in bed should favor both the arterial and 
venous circulation. The clothing should not restrict the neck, and care 
should be taken to avoid bending of the neck. 

The internal administration of potassium iodide and calomel has been 



AFFECTIONS OF THE BLOOD-VESSELS. 



1017 



recommended in the autochthonous forms, but no treatment is likely to he 
of any avail. 

The secondary forms, especially those following upon disease of the 
middle ear, are often amenable to operation, and, especially recently, many 
lives have been saved by surgical intervention after extensive sinus throm- 
bosis. Macewen's work On Pyogenic Infective Diseases of the Brain and 
Spinal Cord contains the most exhaustive presentation of the subject of 
sinus thrombosis and its treatment. 

9. Hemiplegia in Children. 

Etiology. — Of 135 cases, 60 were in boys and 75 in girls. Right 
hemiplegia occurred in 79, left in 56. In 15 cases the condition was said 
to be congenital. 

In a great majority the disease sets in during the first or second year; 
thus of the total number of cases, 95 were under two. Cases above the 
fifth year are rare, only 10 in my series. Neither alcoholism nor syphilis 
in the parents appears to play an important role in this affection. Diffi- 
cult or abnormal labor is responsible for certain of the cases, particularly 
injury with the forceps. Trauma, such as falls or puncturing wounds, 
is more rare. The condition followed ligation of the common carotid in 
one case. 

Infectious diseases. All the authors lay special stress upon this factor. 
In 19 cases in my series the disease came on during or just after one 
of the specific fevers. I saw one case in which during the height of vac- 
cination convulsions developed, followed by hemiplegia. In a great ma- 
jority of the cases the disease sets in with a convulsion, in which the child 
may remain for several hours or longer, and after recovery the paralysis 
is noticed. 

Morbid Anatomy. — In an analysis which I have made of 90 au- 
topsies reported in the literature, the lesions may be grouped under three 
headings: 

(a) Embolism, thrombosis, and haemorrhage, comprising 16 cases, in 
7 of which there was blocking of a Sylvian artery, and in 9 haemorrhage. 
A striking feature in this group is the advanced age of onset. Ten of the 
cases occurred in children over six years old. 

(b) Atrophy and sclerosis, comprising 50 cases. The wasting is either 
of groups of convolutions, an entire lobe, or the whole hemisphere. The 
meninges are usually closely adherent over the affected region, though 
sometimes they look normal. The convolutions are atrophied, firm, and 
hard, contrasting strongly with the normal gyri. The sclerosis may be 
diffuse and widespread over a hemisphere, or there may be nodular pro- 
jections — the hypertrophic sclerosis. Some of the cases show remarkable 
unilateral atrophy of the hemisphere. In one of my cases the atrophied 
hemisphere weighed 169 grammes and the normal one 653 grammes. The 
brain tissue may be a mere shell over a dilated ventricle. 

(c) Porencephalia, which was present in 24 of the 90 autopsies. This 
term was applied by Heschcl (1868) to a loss of substance in the form of 



1018 



DISEASES OF THE NERVOUS SYSTEM. 



cavities and cysts at the surface of the brain, either opening into and 
bounded by the arachnoid, and even passing deeply into the hemisphere, 
or reaching to the ventricle. In the study by Audrey of 103 cases of 
porencephalus, hemiplegia was mentioned in 68 cases. 

Practically, then, in infantile hemiplegia cortical sclerosis and poren- 
cephalus are the important anatomical conditions. The primary change 
in the majority of these cases is still unknown. Porencephalia may result 
from a defect in development or from haemorrhage at birth. The etiology 
is clear in the limited number of cases of haemorrhage, embolism, and 
thrombosis, but there remains the large group in which the final change 
is sclerosis and atrophy. What is the primary lesion in these instances? 
The clinical history shows that in nearly all these cases the onset is sud- 
den, with convulsions — often with slight fever. Striimpell believes that 
this condition is due to an inflammation of the gray matter — polio-en- 
cephalitis — a view which has not been very widely accepted, as the ana- 
tomical proofs are wanting. Gowers suggests that thrombosis may be pres- 
ent in some instances. This might probably account for the final condi- 
tion of sclerosis, but clinically thrombosis of the veins rarely occurs in 
healthy children, which appear to be those most frequently attacked by 
infantile hemiplegia, and post-mortem proof is yet wanting of the associa- 
tion of thrombosis with the disease. 

Symptoms. — (a) The onset. The disease may set in suddenly with- 
out spasms or loss of consciousness. In more than half the cases the child 
is attacked with partial or general convulsions and loss of consciousness, 
which may last from a few hours to many days. This is one of the most 
striking features in the disease. Fever is usually present. The hemi- 
plegia, noticed as the child recovers consciousness, is generally complete. 
Sometimes the paralysis is not complete at first, but develops after subse- 
quent convulsions. The right side is more frequently affected than the 
left. The face is commonly not involved. 

(b) Residual symptoms. In some cases the paralysis gradually disap- 
pears and leaves scarcely a trace as the child grows up. The leg, as a 
rule, recovers more rapidly and more fully than the arm, and the paraly- 
sis may be scarcely noticeable. In a majority of cases, however, there is 
a characteristic hemiplegic gait. The paralysis is most marked in the 
arm, which is usually wasted; the forearm is flexed at right angles, the 
hand is flexed, and the fingers are contracted. Motion may be almost com- 
pletely lost; in other instances the arm can be lifted above the head. Late 
rigidity, which almost always develops, is the symptom which suggested 
the name hemiplegia spastica cerebralis to Heine, the orthopaedic surgeon 
who first accurately described "these cases. It is, however, not constant. 
The limbs may be quite relaxed even years after the onset. The reflexes 
are usually increased. In several instances, however, I have known them 
to be absent. Sensation is, as a rule, not disturbed. 

Aphasia is a not uncommon symptom, and occurred in 16 cases of my 
series — a smaller number than that given in the series of Wallenberg, 
Gaudard, and Sachs. 

Mental Defects. — One of the most serious consequences of infantile 



AFFECTIONS OF THE BLOOD-VESSELS. 



1019 



hemiplegia is the failure of mental development. A considerable number 
of these cases drift into the institutions for feeble-minded children. Three 
grades may be distinguished — idiocy, which is most common when the 
hemiplegia has existed from birth; imbecility, which often increases with 
the development of epilepsy; and feeble-mindedness, a retarded rather 
than an arrested development. 

Epilepsy. — Of the cases in my series, 41 were subjects of convulsive 
seizures, one of the most distressing sequels of the disease. The seizures 
may be either transient attacks of petit mat, true Jacksonian fits, begin- 
ning in and confined to the affected side, or general convulsions. 

Post-hemiplegic Movements. — It was in cases of this sort that Weir 
Mitchell first described the post-hemiplegic movements. They are ex- 
tremely common, and were present in 34 of my series. There may be 
either slight tremor in the affected muscles, or incoordinate choreiform 
movements — the so-called post-hemiplegic chorea — or, lastly, 

Athetosis. — In this condition, described by Hammond, there are remark- 
able spasms of the paralyzed extremities, chiefly of the fingers and toes, 
and in rare instances of the muscles of the mouth. The movements are 
involuntary and somewhat rhythmical; in the hand, movements of adduc- 
tion or abduction and of supination and pronation follow each other in 
orderly sequence. There may be hyperextension of the fingers, during 
which they are spread wide apart. This condition is much more frequent 
in children than in adults. In the latter it may be combined with hemi- 
ansesthesia, and the lesion is not cortical, but basic in the neighborhood of 
the thalamus. The movements are sometimes increased by emotion. They 
usually persist during sleep. 

Treatment. — The possibility of injury to the brain in protracted 
labor and in forceps cases should be borne in mind by the practitioner. 
The former entails the greater risk. In infantile hemiplegia the physician 
at the outset sees a case of ordinary convulsions, perhaps more protracted 
and severe than usual. These should be checked as rapidly as possible 
by the use of the bromides, the application of cold or heat, and a brisk 
purge. During convulsions chloroform may be administered with safety 
even to the youngest children. When the paralysis is established not much 
can be hoped from medicines. In only rare instances does the paralysis 
entirely disappear. When the recovery is partial the " residual paralysis " 
is similar to that seen in other lesions of the upper motor segment. Thus 
in the lower extremity it is the flexors of the leg and the dorsal flexors of 
the foot which are most often permanently paralyzed (Wernicke). The 
indications are to favor the natural tendency to improve by maintaining the 
general nutrition of the child, to lessen the rigidity and contractures by 
massage and passive motion, and if necessary to correct deformities by 
mechanical or surgical measures. Much may be done by careful manipula- 
tion and rubbing and the application of a proper apparatus. In children 
the aphasia usually disappears. The epilepsy is a distressing and obstinate 
symptom, for which a cure can rarely be anticipated. Prolonged periods 
of quiescence are, however, not uncommon. In the Jacksonian fits the 
bromides rarely do good, unless there is much irritability and excitement. 



1020 



DISEASES OF THE NERVOUS SYSTEM. 



Operative measures, which have been carried out in several eases, have not, 
as a rule, been successful. The liability to feeble-mindedness is the most 
serious outlook in the infantile cerebral palsies. In many cases the damage 
is irreparable, and idiocy and imbecility result. With patient training and 
with care many of the children reach a fair measure of intelligence and 
self-reliance. 



IV. TUMORS, INFECTIOUS GRANULOMATA, AND CYSTS 

OF THE BRAIN. 

The following are the most common varieties of new growths within 
the cranium: 

(1) Infectious Granulomata— (a) Tubercle, which may form large or 
small growths, usually multiple. Tuberculosis of the glands or bones may 
be coexistent, but the tuberculous disease of the brain may occur in the 
absence of other clinically recognizable tuberculous lesions. The disease is 
most frequent early in life. Three fourths of the cases occur under twenty, 
and one half of the patients are under ten years of age (Gowers). Of 299 
cases of tumor in persons under nineteen collected from various sources 
by Starr, 152 were tubercle. The nodules are most numerous in the cere- 
bellum and about the base. 

(b) Syphiloma is most commonly found in the hemispheres or about 
the pons. The tumors are superficial, attached to the arteries or the me- 
ninges, and rarely grow to a large size. They may be multiple. The third 
nerve is particularly prone to syphilitic infiltration, and ptosis is common. 

(2) Tumors. — (c) Glioma and Neuroglioma. — These vary greatly in ap- 
pearance. They may be firm and hard, almost like an area of sclerosis, 
or soft and very vascular. They persist remarkably for many years. Klebs 
has called attention to the occurrence of elements in them not unlike gan- 
glion-cells. Tumors of this character may contain the " Spinnen " or spider 
cells; enormous spindle-shaped cells with single large nuclei; cells like the 
ganglion-cells of nerve-centres with nuclei and one or more processes; and 
translucent, band-like fibres, tapering at each end, which result from a 
vitreous or hyaline transformation of the large spindle-cells. A separate 
type is also recognizable, in which the cells resemble the ependymal epi- 
thelium. 

(d) Sarcoma occurs most commonly in the membranes of the brain and 
in the pons. It forms some of the largest and most diffusely infiltrating 
of intracranial growths. Like carcinoma, sarcoma of the brain is usually 
of very rapid growth. 

(e) Carcinoma not infrequently is secondary to cancer in other parts. 
It is seldom primary. Occasionally cancerous tumors have been found in 
symmetrical parts of the brain. 

(f) Other varieties occur, such as fibroid growths, which usually develop 
from the membranes; bony tumors, which grow sometimes from the falx, 
psammoma, and cholesteatoma. Fatty tumors are occasionally found on 
the corpus callosum. 



TUMORS, INFECTIOUS GRANULOMATA, AND CYSTS OF THE BRAIN. 1021 



(3) Cysts. — (g) These occur between the membranes and the brain, as 
a result of haemorrhage or of softening. Porencephalus is a sequel of con- 
genital atrophy or of haemorrhage, or may be due to a developmental de- 
fect. Hydatid cysts have been referred to in the section on parasites. An 
interesting variety of cyst is that which follows severe injury to the skull 
in early life. 

Symptoms. — (1) General. — The following are the most important: 
Headache, either dull, aching, and continuous, or sharp, stabbing, and par- 
oxysmal. It may be diffused over the entire head; sometimes it is limited 
to the back or front. When in the back of the head it may extend down 
the neck (especially in tumors in the posterior fossa), and when in the front 
it may be accompanied with neuralgic pains in the face. Occasionally the 
pain may be very localized and associated with tenderness on pressure. 

Optic neuritis occurs in four fifths of all the cases (Growers). It is usu- 
ally double, but occasionally is found in only one eye. A growth may de- 
velop slowly and attain considerable size without producing optic neuritis. 
On the other hand, it may occur with a very small tumor. J. A. Martin, 
from an extensive analysis of the literature with reference to the localizing 
value, concludes: When there is a difference in the amount of the neuritis 
in each eye it is more than twice as probable that the tumor is on the side 
of the most marked neuritis. It is constant in tumors of the corpora 
quadrigemina, present in 89 per cent of cerebellar tumors, and absent in 
nearly two thirds of the cases of tumor of the pons, medulla, and of the 
corpus callosum. It is least frequent in cases of tuberculous tumor; most 
common in cases of glioma and cystic tumors. 

Vomiting is a common feature, and with headache and optic neuritis 
makes up the characteristic clinical picture of cerebral tumor. An impor- 
tant point is the absence of definite relation to the meals. A chemical ex- 
amination shows that the vomiting is independent of digestive disturbances. 
It may be very obstinate, particularly in growths of the cerebellum and 
the pons. 

Giddiness is often an early symptom. The patient complains of vertigo 
on rising suddenly or on turning quickly. Mental Disturbance. — The pa- 
tient may act in an odd, unnatural manner, or there may be stupor and 
heaviness. The patient may become emotional or silly, or symptoms re- 
sembling hysteria may develop. Convulsions, either general and resembling 
true epilepsy or localized (Jacksonian) in character. There may be slowing 
of the pulse, as in all cases of increased intracranial pressure. 

(2) Localizing Symptoms. — Focal symptoms often occur, but it must not 
be forgotten that these may be indirectly produced. The smaller the tumor 
and the less marked the general symptoms of cerebral compression, the 
more likely is it that any focal symptoms occurring are of direct origin. 

(a) Central Motor Area. — The symptoms are either irritative or destruc- 
tive in character. Irritation in the lower third may produce spasm in the 
muscles of the face, in the angle of the mouth, or in the tongue. The 
spasm with tingling may be strictly limited to one muscle group before ex- 
tending to others, and this Seguin terms the signal symptom. The middle 
third of the motor area contains the centres controlling the arm, and here. 
64 



1022 



DISEASES OF THE NERVOUS SYSTEM. 



too, the spasm may begin in the fingers, in the thumb, in the muscles of 
the wrist, or in the shoulder. In the upper third of the motor areas the 
irritation may produce spasm beginning in the toes, in the ankles, or in the 
muscles of the leg. In many instances the patient can determine accu- 
rately the point of origin of the spasm, and there are important sensory 
disturbances, such as numbness and tingling, which may be felt first at 
the region affected. 

In all cases it is important to determine, first, the point of origin, the 
signal symptom; second, the order or march of the spasm; and third, the 
subsequent condition of the parts first affected, whether it is a state of 
paresis or anaesthesia. 

Destructive lesions in the motor zone cause paralysis, which is often 
preceded by local convulsive seizures; there may be a monoplegia, as of 
the leg, and convulsive seizures in the arm, often due to irritation in these 
centres. Tumors in the neighborhood of the motor area may cause local- 
ized spasms and subsequently, as the centres are invaded by the growth, 
paralysis occurs. On the left side, growths in the third frontal or Br oca's 
convolution may cause motor aphasia. 

(b) Prefrontal Region. — Neither motor nor sensory disturbance may 
be present. The general symptoms are often well marked. The most 
striking feature of growths in this region is mental torpor and gradual 
imbecility. In its extension downward the tumor may involve on the left 
side the lower frontal convolution and produce aphasia, or in its progress 
backward cause irritative or destructive lesions of the motor area. Ex- 
ophthalmos on the side of the tumor may occur and be helpful in diagnosis, 
as in the case reported by Thomas and Keene. 

(c) Tumors in the parieto-occipital lobe may grow to a large size without 
causing any symptoms. There may be word-blindness and mind-blindness 
when the angular gyrus and its underlying white matter is involved, and 
paraphasia. 

(d) Tumors of the occipital lobe produce hemianopia, and a bilateral 
lesion may produce blindness. Tumors in this region on the left hemi- 
sphere may be associated with word-blindness and mind-blindness. 

(e) Tumors in the temporal lobe may attain a large size without produc- 
ing symptoms. In their growth they involve the lower motor centres. On 
the left side involvement of the first gyrus and the transverse temporal 
gyri (auditory sense area) may be associated with word-deafness. 

(f) Tumors growing in the neighborhood of the basal ganglia produce 
hemiplegia from involvement of the internal capsule. Limited growths in 
either the nucleus caudatus or the nucleus lentif ormis of the corpus striatum 
do not necessarily cause paralysis. Tumors in the thalamus opticus may 
also, when small, cause no symptoms, but increasing they may involve the 
fibres of the sensory portion of the internal capsule, producing hemianopia 
and sometimes hemianesthesia. Growths in this situation are apt to cause 
early optic neuritis, and, growing into the third ventricle, may cause a dis- 
tention of the lateral ventricles. In fact, pressure symptoms from this 
cause and paralysis due to involvement of the internal capsule are the chief 
symptoms of tumor in and about these ganglia. If the ventrolateral group 



TUMORS, INFECTIOUS GRANULOMATA, AND CYSTS OF THE BRAIN. 1023 



of nuclei in the thalamus be involved there may be unilateral disturbances 
of cutaneous and muscular sense, hemichorea, or movement ataxia. 

Growths in the corpora quadrigemina are rarely limited, but most com- 
monly involve the crura cerebri as well. Ocular symptoms are marked. 
The pupil reflex is lost and there is nystagmus. In the gradual growth 
the third nerve is involved as it passes through the eras, in which case there 
will be oculo-motor paralysis on one side and hemiplegia on the other, a 
combination almost characteristic of unilateral disease of the eras. 

(g) Tumors of the pons and medulla. The symptoms are chiefly those 
of pressure upon the nerves emerging in this region. In disease of the 
pons the nerves may be involved alone or with the pyramidal tract. Of 52 
cases analyzed by Mary Putnam Jacobi, there were 13 in which the cerebral 
nerves were involved alone, 13 in which the limbs were affected, and 26 in 
which there was hemiplegia and involvement of the nerves. Twenty-two 
of the latter had what is known as alternate paralysis — i. e., involvement 
of the nerves on one side and of the limbs on the opposite side. In 4 cases 
there were no motor symptoms. In tuberculosis (or syphilis) a growth 
at the inferior and inner aspects of the eras may cause paralysis of the 
third nerve on one side, and of the face, tongue, and limbs on the opposite 
side (syndrome of Weber). A tumor growing in the lower part of the pons 
usually involves the sixth nerve, producing internal strabismus; the seventh 
nerve, producing facial paralysis; and the auditory nerve, causing deaf- 
ness. Conjugate deviation of the eyes to the side opposite that on which 
there is facial paralysis also occurs. When the motor cerebral nerves are 
involved the paralyses are of the peripheral type (lower segment paralyses). 

Tumors of the medulla may involve the cerebral nerves alone or cause 
in some instances a combination of hemiplegia with paralysis of the nerves. 
Paralyses of the nerves are helpful in topical diagnosis, but the fact must not 
be overlooked that one or more of the cerebral nerves may be paralyzed as 
a result of a much increased general intracranial pressure. Signs of irrita- 
tion in the ninth, tenth, and eleventh nerves are usually present, and pro- 
duce difficulty in swallowing, irregular action of the heart, irregular respira- 
tion, vomiting, and sometimes retraction of the head and neck. The hypo- 
glossal nerve is least often affected. The gait may be unsteady or, if 
there is pressure on the cerebellum, ataxic. Occasionally there are sen- 
sory symptoms, numbness, and tingling. Toward the end convulsions may 
occur. 

Diagnosis. — From the general symptoms alone the existence of tumor 
may be determined, for the combination of headache, optic neuritis, and 
vomiting is distinctive. A gradual increase in the intensity of the symp- 
toms is usually seen. It must not be forgotten that severe headache and 
neuro-retinitis may be caused by Bright's disease. The localization must 
be gathered from the consideration of the symptoms above detailed and 
from the data given in the section on Topical Diagnosis of Diseases of the 
Brain. Mistakes are most likely to occur in connection with uraemia, hys- 
teria, and general paralysis; but careful consideration of all the circum- 
stances of the case usually enables the practitioner to avoid error. Auscul- 
tatory percussion is occasionally of service in localization. 



1024 



DISEASES OF THE NERVOUS SYSTEM. 



Prognosis. — Syphilitic tumors alone are amenable to medical treat- 
ment. Tuberculous growths occasionally cease to grow and become calci- 
iied. The gliomata and fibromata, particularly when the latter grow from 
the membranes, may last for years. I have described a case of small, hard 
glioma, in which the Jacksonian epilepsy persisted for fourteen years. 
Hughlings Jackson has reported cases of glioma in which the symptoms 
lasted for over ten years. The more rapidly growing sarcomata usually 
prove fatal in from six to eighteen months. Death may be sudden, par- 
ticularly in growths near the medulla; more commonly it is due to coma 
in consequence of gradual increase in the intracranial pressure. 

Treatment. — (a) Medical. — If there is a suspicion of syphilis the 
iodide of potassium and mercury should be given. Nowhere do we see 
more brilliant therapeutical effects than in certain cases of cerebral gum- 
mata. The iodide should be given in increasing doses. In tuberculous 
tumors the outlook is less favorable, though instances of cure are reported, 
and there is post-mortem evidence to show that the solitary tuberculous 
tumors may undergo changes and become obsolete. A general tonic treat- 
ment is indicated in these cases. The headache usually demands prompt 
treatment. The iodide of potassium in full doses sometimes gives marked 
relief. An ice-cap for the head or, in the occipital headache, the appli- 
cation of the Paquelin cautery may be tried. The bromides are not of 
much use in the headache from this cause, and, as the last resort, mor- 
phia must be given. For the convulsions bromide of potassium is of little 
service. 

(b) Surgical. — Tumors of the brain have been successfully removed by 
Macewen, Horsley, Keen, and others. The number of cases for operation, 
however, is small. Four fifths at least of all the cases are probably un- 
suitable, or of such a nature as to render an operation fatal. The most 
advantageous cases are the localized fibromata growing from the dura and 
only compressing the brain substance, as in Keen's remarkable case. The 
safety with which the exploratory operation can be made warrants it in all 
doubtful cases. 

V. INFLAMMATION OF THE BRAIN. 

1. Acute Encephalitis. 

A focal or diffuse inflammation of the brain substance, usually of the 
gray matter (periencephalitis), is met with (a) as a result of trauma; (&) 
in certain intoxications, alcohol, food poisoning, and gas poisoning; and (c) 
following the acute infections. The anatomical features are those of an 
acute hemorrhagic poliencephalitis, corresponding in histological details 
with acute polio-myelitis. Focal forms are seen in ulcerative endocarditis, 
in which the gray matter may present deeply hemorrhagic areas, firmer 
than the surrounding tissue. In the fevers there may be more extensive 
regions, involving two or three convolutions. This acute hasmorrhagic 
poliencephalitis superior is thought by Strumpell to be the essential lesion 
in infantile hemiplegia. Localizing symptoms are usually present, though 



INFLAMMATION OF THE BRAIN. 



1025 



they may be obscured in the severity of the general infection. The most 
typical encephalitis accompanies the meningitis in cerebro-spinal fever. 

In acute mania, in delirium tremens, in chorea insaniens, in the mani- 
acal form of exophthalmic goitre, and in the so-called cerebral forms of the 
malignant fevers the gray cortex is deeply congested, moist, and swollen, 
and with the recent finer methods of research will probably show changes 
which may be classed as encephalitis. 

The symptoms are not very definite. In severe forms they are those of 
an acute infection; some cases have been mistaken for typhoid fever. The 
onset may be abrupt in an individual apparently healthy. Other cases 
have occurred in the convalescence from the fevers, particularly influenza. 
One of J. J. Putnam's cases followed mumps. The general symptoms are 
those which accompany all severe acute affections of the brain — headache, 
somnolence, coma, delirium, vomiting, etc. The local symptoms are very 
varied, depending on the extent of the lesions, and may be irritative or 
paralytic. Usually fatal within a few weeks, cases may drag on for weeks 
or months and recover. 

2. Abscess of the Bkain. 

Etiology. — Suppuration of the brain substance is rarely if ever pri- 
mary, but results, as a rule, from extension of inflammation from neigh- 
boring parts or infection from a distance through the blood. The question 
of idiopathic brain abscess need scarcely be considered, though occasion- 
ally instances occur in which it is extremely difficult to assign a cause. 
There are three important etiological factors: 

(1) Trauma. Falls upon the head or blows, with or without abrasion 
of the skin. More commonly it follows fracture or punctured wounds. In 
this group meningitis is frequently associated with the abscess. 

(2) By far the most important infective foci are those which arise in 
direct extension from disease of the middle ear or of the mastoid cells. 
From the roof of the mastoid antrum the infection readily passes to the 
sigmoid sinus and induces an infective thrombosis. In other instances the- 
dura becomes involved, and a sub-dural abscess is formed, which may 
readily involve the arachnoid or the pia mater. In another group the in- 
flammation extends along the lymph spaces, or the thrombosed veins, into 
the substance of the brain and causes suppuration. Macewen thinks that 
without local areas of meningitis the infective agents may be carried 
through the lymph and blood channels into the cerebral substance. In- 
fection which extends from the roof of the mastoid process is most likely 
to be followed by abscess in the temporal lobe, while infection extending 
from the posterior wall causes most frequently sinus thrombosis and cere- 
bellar abscess. 

(3) In septic processes. Abscess of the brain is not often found in 
pyaemia. In ulcerative endocarditis multiple foci of suppuration are com- 
mon. Localized bone-disease and suppuration in the liver are occasional 
causes. Certain inflammations in the lungs, particularly bronchiectasis, 
which was present in 17 of 38 cases of these so-called " pulmonal cerebral 



1026 



DISEASES OF THE NERVOUS SYSTEM. 



abscesses " collected by E. T. Williamson, are liable to be followed by ab- 
scess. It is an occasional complication of empyema. Abscess of the brain 
may follow the specific fevers. Bristowe has called attention to its occur- 
rence as a sequel of influenza. The largest number of cases occur between 
the twentieth and fortieth years, and the condition is more frequent in men 
than in women. Holt has collected 25 cases in children under five years 
of age, the chief causes of which were otitis media and trauma. 

Morbid Anatomy. — The abscess may be solitary or multiple, dif- 
fuse or circumscribed. Practically any one of the different varieties of 
pyogenic bacteria may be concerned. The bacteriological examination 
often shows a mixture of different varieties. Occasionally cultures are 
sterile, owing to death of the bacteria. In the acute, rapidly fatal cases 
following injury the suppuration is not limited; but in long-standing cases 
the abscess is enclosed in a definite capsule, which may have a thickness of 
from 2 to 5 mm. The pus varies much in appearance, depending upon 
the age of the abscess. In early cases it may be mixed with reddish debris 
and softened brain matter, but in the solitary encapsulated abscess the pus 
is distinctive, having a greenish tint, an acid reaction, and a peculiar odor, 
sometimes like that of sulphuretted hydrogen. The brain substance sur- 
rounding the abscess is usually cedematous and infiltrated. The size varies 
from that of a walnut to that of a large orange. There are cases on record 
in which the cavity has occupied the greater portion of a hemisphere. Mul- 
tiple abscesses are usually small. In four fifths of all cases the abscess is 
solitary. Suppuration occurs most frequently in the cerebrum, and the 
temporal lobe is more often involved than other parts. The cerebellum is 
the next most common seat, particularly in connection with ear-disease. 

Symptoms. — Following injury or operation the disease may run an 
acute course, with fever, headache, delirium, vomiting, and rigors. The 
symptoms are those of an acute meningo-encephalitis, and it may be very 
difficult to determine, unless there are localizing symptoms, whether there 
is really suppuration in the brain substance. In the cases following ear 
disease the symptoms may at first be those of meningeal irritation. There 
may be irritability, restlessness, severe headache, and aggravated earache. 
Other striking symptoms, particularly in the more prolonged cases, are 
drowsiness, slow cerebration, vomiting, and optic neuritis. In the chronic 
form of brain abscess which may follow injury, otorrhcea, or local lung 
trouble, there may be a latent period ranging from one or two weeks to 
several months, or even a year or more. In the " silent 99 regions, when 
the abscess becomes encapsulated there may be no symptoms whatever 
during the latent period. During all this time the patient may be under 
careful observation and no suspicion be aroused of the existence of sup- 
puration. Then severe headache, vomiting, fever, set in, perhaps with a 
chill. So, too, after a blow upon the head or a fracture the symptoms of 
the lesion may be transient, and months afterward cerebral symptoms of the 
most aggravated character may develop. 

The localization of the lesion is often difficult. In or near the motor 
region there may be convulsions or paralysis, and it is to be remembered 
that an abscess in the temporal lobe may compress the lower motor centres 



INFLAMMATION OF THE BRAIN. 



1027 



and produce paralysis of the arm and face and on the left side cause aphasia. 
A large abscess may exist in the frontal lobe without causing paralysis, but 
in these cases there is almost always some mental dulness. In the temporal 
lobe, the common seat, there may be no focalizing symptoms. So also in 
the parieto-occipital region; though here early examination may lead to 
the detection of hemianopia. In abscess of the cerebellum vomiting is com- 
mon. If the middle lobe is affected there may be staggering — cerebellar 
incoordination. Localizing symptoms in the pons and other parts are still 
more uncertain. 

Diagnosis. — In the acute cases there is rarely any doubt. A considera- 
tion of possible etiological factors is of the highest importance. The history 
of injury followed by fever, marked cerebral symptoms, the development 
of rigors, delirium, and perhaps paralysis, make the diagnosis certain. In 
chronic ear-disease, such cerebral symptoms as drowsiness and torpor, with 
irregular fever, supervening upon the cessation of a discharge, should ex- 
cite the suspicion of abscess. Cases in which suppurative processes exist 
in the orbit, nose, or naso-pharynx, or in which there has been subcutaneous 
phlegmon of the head or neck, a parotitis, a facial erysipelas, or tuberculous 
or syphilitic disease of the bones of the skull, should be carefully watched, 
and immediately investigated should cerebral symptoms appear. It is par- 
ticularly in the chronic cases that difficulties arise. The symptoms resem- 
ble those of tumor of the brain; indeed, they are those of tumor plus fever. 
Choked disk, however, so commonly associated with tumor, is very fre- 
quently absent in abscess of the brain. In a patient with a history of trauma 
or with localized lung or pleural trouble, who for weeks or months has had 
slight headache or dizziness, the onset of a rapid fever, especially if it be in- 
termittent and associated with rigors, intense headache, and vomiting, point 
strongly to abscess. The pulse-rate in cases of cerebral abscess is usually 
accelerated, but cases are not rare in which it is slowed. Macewen lays stress 
upon the value of percussion of the skull as an aid in diagnosis. The note, 
which is uniformly dull, becomes much more resonant when the lateral 
ventricles are distended in cerebellar abscess and in conditions in which the 
venae Galeni are compressed. 

It is not always easy to determine whether the meninges are involved 
with the abscess. Often in ear-disease the condition is that of meningo- 
encephalitis. Sometimes in association with acute ear-disease the symp- 
toms may simulate closely cerebral meningitis or even abscess. Indeed, 
Gowers states that not only may these general symptoms be produced by 
ear-disease, but even distinct optic neuritis. 

Treatment. — A remarkable advance has been made of late years in 
dealing with these cases, owing to the impunity with which the brain can 
be explored. In ear-disease free discharge of the inflammatory products 
should be promoted and careful disinfection practised. The treatment of 
injuries and fractures comes within the scope of the surgeon. The acute 
symptoms, such as fever, headache, and delirium, must he treated by rest, 
an ice-cap, and, if necessary, local depletion. In all cases, when a reason- 
able suspicion exists of the occurrence of abscess, the trephine should be 
used and the brain explored. The cases following ear-disease, in which 



1028 



DISEASES OF THE NERVOUS SYSTEM, 



the suppuration is in the temporal lobe or in the cerebellum, offer the most 
favorable chances of recovery. The localization can rarely be made ac- 
curately in these cases, and the operator must be guided more by general 
anatomical and pathological knowledge. In cases of injury the trephine 
should be applied over the seat of the blow or the fracture. In ear-disease 
the suppuration is most frequent in the temporal lobe or in the cerebellum, 
and the operation should be performed at the points most accessible to these 
regions. And, lastly, a most important, one might almost say essential, 
factor in the successful treatment of intracranial suppuration is an intelli- 
gent knowledge on the part of the surgeon of the work and works of William 
Macewen. 

VI. HYDROCEPHALUS. 

Definition. — A condition, congenital or acquired, in which there is 
a great accumulation of fluid within the ventricles of the brain. 

The term hydrocephalus has also been applied to the collection of fluid 
between the cortex of the brain and the skull, known in this situation as 
h. externus or h. ex vacuo, a condition common in cases of atrophy of the 
brain substance, met with in old age, after haemorrhages, softenings, or 
scleroses, in lingering and cachectic diseases, as cancer, chronic nephritis, 
chronic alcoholism, and sometimes in rickets. Occasionally the disease is 
caused by meningeal cysts. A true dropsy, however, of the arachnoid sac 
probably does not occur. 

The cases may be divided into three groups — idiopathic internal hydro- 
cephalus (serous meningitis), congenital or infantile, and secondary or ac- 
quired. 

(1) Serous Meningitis (Quincke) (Idiopathic Internal Hydrocephalus; 
Angio-neurotic Hydrocephalus). — This remarkable form, described by 
Quincke, is very important, since a knowledge of the condition may explain 
very anomalous and puzzling cases. It is an ependymitis causing a serous 
effusion into the ventricles, with distention and pressure effects. It may be 
compared to the serous exudates in the pleura or in synovial membranes. 
It is not certain that the process is inflammatory, and Quincke likens it to 
the angio-neurotic oedema of the skin. In very acute cases the ependyma 
may be smooth and natural looking; in more chronic cases it may be thick- 
ened and sodden. The exudate does not differ from the normal, and if on 
lumbar puncture a fluid is removed of a specific gravity above 1.009, with 
albumin above two per one thousand, the condition is more likely to be 
hydrocephalus from stasis, secondary to tumor, etc. 

Both children and adults are affected, the latter more frequently. In 
the acute form the condition is mistaken for tuberculous or purulent men- 
ingitis. There are headache, retraction of the neck, and signs of increased 
intracranial pressure, choked disks, slow pulse, etc. Fever is usually ab- 
sent, but I have seen one case with recurring paroxysms of fever, and Morton 
Prince has described a similar one. In both the exudate was clear and the 
ependyma not acutely inflamed. Quincke has reported cases of recovery. 
In the chronic form the symptoms are those of tumor — general, such as 



HYDROCEPHALUS. 



1029 



headache, slight fever, somnolence, and delirium; and local, as exophthal- 
mos, optic neuritis, spasms, and rigidity of muscles and paralysis of the 
cerebral nerves. Eemarkable exacerbations occur, and the symptoms vary 
in intensity from day to day. Eecovery may follow after an illness of many 
weeks, and some of the reported cases of disappearance of all symptoms of 
brain tumor belong in this category. 

(2) Congenital Hydrocephalus. — The enlarged head may obstruct labor; 
more frequently the condition is noticed some time after birth. The cause 
is unknown. It has occurred in several members of the same family. 

The anatomical condition in these cases offers no clew to the nature of 
the trouble. The lateral ventricles are enormously distended, but the 
ependyma is usually clear, sometimes a little thickened and granular, and 
the veins large. The choroid plexuses are vascular, sometimes sclerotic, but 
often natural looking. The third ventricle is enlarged, the aqueduct of 
Sylvius dilated, and the fourth ventricle may be distended. The quantity 
of fluid may reach several litres. It is limpid and contains a trace of albu- 
min and salts. The changes in consequence of this enormous ventricular 
distention are remarkable. The cerebral cortex is greatly stretched, and 
over the middle region the thickness may amount to no more than a few 
millimetres without a trace of the sulci or convolutions. The basal ganglia 
are flattened. The skull enlarges, and the circumference of the head of 
a child of three or four years may reach 25 or even 30 inches. The sutures 
widen, Wormian bones develop in them, and the bones of the cranium 
become exceedingly thin. The veins are marked beneath the skin. A fluc- 
tuation wave may sometimes be obtained, and Fisher's brain murmur may 
be heard. The orbital plates of the frontal bone are depressed, causing 
exophthalmos, so that the eyeballs cannot be covered by the eyelids. The 
small size of the face, widening somewhat above, is striking in comparison 
with the enormously expanded skull. 

Convulsions may occur. The reflexes are increased, the child learns to 
walk late, and ultimately in severe cases the legs become feeble and some- 
times spastic. Sensation is much less affected than motility. Choked disk 
is not uncommon. The mental condition is variable; the child may be 
bright, but, as a rule, there is some grade of imbecility. The congenital 
cases usually die within the first four or five years. The process may be 
arrested and the patient may reach adult life. Cases of this sort are not 
very uncommon. Even when extreme, the mental faculties may be retained, 
as in Bright's celebrated patient, Cardinal, who lived to the age of twenty- 
nine, and whose head was translucent when the sun was shining belli nd 
him. Care must be taken not to mistake the rachitic head for hydro- 
cephalus. 

(3) Acquired Chronic Hydrocephalus. — This is stated to be occasionally 
primary (idiopathic) — that is to say, it comes on spontaneously in the 
adult without observable lesion. Dean Swift is said to have died of hydro- 
cephalus, but this seems very unlikely. It is based upon the statement 
that "he (Mr. Whiteway) opened the skull and found much water in the 
brain," a condition no doubt of h. ex vacuo, due to the wasting associated 
with his prolonged illness and paralysis. In nearly all cases there is either 



1030 



DISEASES OF THE NERVOUS SYSTEM. 



a tumor at the base of the brain or in the third ventricle, which compresses 
the venae Galeni. The passage from the third to the fourth ventricle may 
be closed, either by a tumor or by parasites. More rarely the foramen of 
Magendie, through which the ventricles communicate with the cerebro- 
spinal meninges, becomes closed by meningitis. These conditions, occur- 
ring in adults, may produce the most extreme hydrocephalus without any 
enlargement of the head. Even when the tumor begins early in life there 
may be no expansion of the skull. In the case of a girl aged sixteen, blind 
from her third year, the head was not unusually large, the ventricles were 
enormously distended, and in the Eolandic region the brain substance was 
only 5 mm. in thickness. A tumor occupied the third ventricle. In a case 
of cholesteatoma of the floor of the third ventricle, in which the symptoms 
persisted at intervals for eight or nine years, the ventricles were enormously 
distended without enlargement of the skull. In other instances the sutures 
separate and the head gradually enlarges. 

The symptoms of hydrocephalus in the adult are curiously variable. 
In the first case mentioned there were early headaches and gradual blind- 
ness; then a prolonged period in which she was able to attend to her studies. 
Headaches again supervened, the gait became irregular and somewhat 
ataxic. Death occurred suddenly. In the other case there were prolonged 
attacks of coma with a slow pulse, and on one occasion the patient remained 
unconscious for more than three months. Gradually progressing optic 
neuritis without focalizing symptoms, headache, and attacks of somnolence 
or coma are suggestive symptoms. These cases of acquired chronic hydro- 
cephalus cannot be certainly diagnosed during life, though in certain in- 
stances the condition may be suspected. 

Treatment. — Very little can be done to relieve hydrocephalus. Medi- 
cines are powerless to cause the absorption of the fluid. More rational is 
the system of gradual compression, with or without the withdrawal of small 
quantities of the fluid. The compression may be made by means of broad 
plasters, so applied as to cross each other on the vertex, and another may 
be placed round the circumference. In the meningitis serosa Quincke ad- 
vises the use of mercury. 

Of late years puncture of the ventricles, an operation which has been 
abandoned, has been revived; it has been resorted to in the meningitis 
serosa. When pressure symptoms are marked Quincke's procedure may be 
used. He recommends puncture of the subarachnoid sac between the third 
and the fourth lumbar vertebrae. At this point the spinal cord cannot be 
touched. The advantages are a slower removal of fluid and less danger of 
collapse. 



NEURITIS. 



1031 



VI. DISEASES OF THE PEEIPHEEAL NERVES. 

I . NEURITIS (Inflammation of the Bundles of Nerve Fibres). 

Neuritis may be localized in a single nerve, or general, involving a large 
number of nerves, in which case it is usually known as multiple neuritis or 
polyneuritis. 

Etiology. — Localized neuritis arises from (a) cold, which is a very fre- 
quent cause, as, for example, in the facial nerve. This is sometimes known 
as rheumatic neuritis. (b) Traumatism — wounds, blows, direct pressure on 
the nerves, the tearing and stretching which follow a dislocation or a frac- 
ture, and the hypodermic injection of ether. Under this section come also 
the professional palsies, due to pressure in the exercise of certain occupa- 
tions, (c) Extension of inflammation from neighboring parts, as in a neuri- 
tis of the facial nerve due to caries in the temporal bone, or in that met 
with in syphilitic disease of the bones, disease of the joints, and occasionally 
in tumors. 

Multiple neuritis has a very complex etiology, the causes of which may 
be classified as follows: (a) The poisons of infectious diseases, as in leprosy, 
diphtheria, typhoid fever, small-pox, scarlet fever, and occasionally in other 
forms; (b) the organic poisons, comprising the diffusible stimulants, such 
as alcohol and ether, bisulphide of carbon and naphtha, and the metallic 
bodies, such as lead, arsenic, and mercury; (c) cachectic conditions, such as 
occur in anaemia, cancer, tuberculosis, or marasmus from any cause; (d) the 
endemic neuritis or beri-beri; and (e) lastly, there are cases in which none 
of these factors prevail, but the disease sets in suddenly after overexertion 
or exposure to cold. 

Morbid Anatomy. — In neuritis due to the extension of inflamma- 
tion the nerve is usually swollen, infiltrated, and red in color. The inflam- 
mation may be chiefly perineural or it may pass into the deeper portion — 
interstitial neuritis — in which form there is an accumulation of lymphoid 
elements between the nerve bundles. The nerve fibres themselves may not 
appear involved, but there is an increase in the nuclei of the sheath of 
Schwann. The myelin is fragmented, the nuclei of the internodal cells are 
swollen, and the axis cylinders present varicosities or undergo granular de- 
generation. Ultimately the nerve fibres may be completely destroyed and 
replaced by a fibrous connective tissue in which much fat is sometimes de- 
posited — the lipomatous neuritis of Leyden. 

In other instances the condition is termed parenchymatous neuritis, in 
which the changes are like those met with in the secondary or Wallerian 
degeneration, which follows when the nerve fibre is cut oft' from the eel] 
body of the neurone to which it belongs. The medullary substance and the 
axis cylinders are chiefly involved, the interstitial tissue being but little 
altered or only affected secondarily. The myelin becomes segmented and 
divides into small globules and grannies, and the axis cylinders become 
granular, broken, subdivided, and ultimately disappear. The nuclei of the 
sheath of Schwann proliferate and ultimately the fibres are reduced to a 



1032 



DISEASES OF THE NERVOUS SYSTEM. 



state of atrophic tubes without a trace of the normal structure. The mus- 
cles connected with the degenerated nerves usually show marked atrophic 
changes, and in some instances the change in the nerve sheath appears to 
extend directly to the interstitial tissue of the muscles — the neuritis fascians 
of Eichhorst. 

Symptoms.— {a) Localized Neuritis. — As a rule the constitutional 
disturbances are slight. The most important symptom is pain of a boring 
or stabbing character, usually felt in the course of the nerve and in the 
parts to which it is distributed. The nerve itself is sensitive to pressure, 
probably, as Weir Mitchell suggests, owing to the irritation of its nervi 
nervorum. The skin may be slightly reddened or even (edematous over 
the seat of the inflammation. Mitchell has described increase in the tem- 
perature and sweating in the affected region, and such trophic disturbances 
as effusion into the joints and herpes. The function of the muscle to which 
the nerve fibres are distributed is impaired, motion is painful, and there 
may be twitchings or contractions. The tactile sensation of the part may 
be somewhat deadened, even when the pain is greatly increased. In the 
more chronic cases of local neuritis, such, for instance, as follow the dis- 
location of the humerus, the localized pain, which at first may be severe, 
gradually disappears, though some sensitiveness of the brachial plexus may 
persist for a long time, and the nerve cords may be felt to be swollen and 
firm. The pain is variable — sometimes intense and distressing; at others 
not causing much inconvenience. Numbness and formication may be pres- 
ent and the tactile sensation may be greatly impaired. The motor disturb- 
ances are marked. Ultimately there is extreme atrophy of the muscles. 
Contractures may occur in the fingers. The skin may be reddened or glossy, 
the subcutaneous tissue ©edematous, and the nutrition of the nails may be 
defective. In the rheumatic neuritis subcutaneous fibroid nodules may 
develop. 

A neuritis limited at first to a peripheral nerve may extend upward — 
the so-called ascending or migratory neuritis — and involve the larger nerve 
trunks, or even reach the spinal cord, causing subacute myelitis (Growers). 
The condition is rarely seen in the neuritis from cold, or in that which 
follows fevers; but it occurs most frequently in traumatic neuritis. J. K. 
Mitchell, in his monograph On Injuries of Nerves (1895), concludes that 
the larger nerve trunks are most susceptible, and that the neuritis may 
spread either up or down, the former being the most common. The paraly- 
sis secondary to visceral disease, as of the bladder, may be due to an ascend- 
ing neuritis. The inflammation may extend to the nerves of the other side, 
either through the spinal cord or its membranes, or without any involve- 
ment of the nerve centres, the so-called sympathetic neuritis. The elec- 
trical changes in localized neuritis vary a great deal, depending upon the 
extent to which the nerve is injured. The lesion may be so slight that the 
nerve and the muscles to which it is distributed may react normally to both 
currents; or it may be so severe that the typical reaction of degeneration 
develops within a few days — i. e., the nerve does not respond to stimula- 
tion by either current, while the muscle reacts only to the galvanic current 
and in a peculiar manner. The contraction caused is slow and lazy, instead 



NEURITIS. 



1033 



of sharp and quick as in the normal muscle, and the AnC contraction is 
usually stronger than the CC contraction. Between these two extremes 
there are many dilf erent grades, and a careful electrical examination is most 
important as an aid to diagnosis and prognosis.* 

The duration varies from a few days to weeks or months. A slight trau- 
matic neuritis may pass off in a day or two, while the severer cases, such as 
follow unreduced dislocation of the humerus, may persist for months or 
never be completely relieved. 

(h) Multiple Neuritis. — This presents a complex symptomatology. The 
following are the most important groups of cases: 

(1) Acute Febrile Polyneuritis. — The attack follows exposure to cold 
or overexertion, or, in some instances, comes on spontaneously. The onset 
resembles that of an acute infectious disease. There may be a definite 
chill, pains in the back and limbs or joints, so that the case may be thought 
to be acute rheumatism. The temperature rises rapidly and may reach 
103° or 104°. There are headache, loss of appetite, and the general symp- 
toms of acute infection. The limbs and back ache. Intense pain in the 
nerves, however, is by no means constant. Tingling and formication are 
felt in the fingers and toes, and there is increased sensitiveness of the nerve 
trunks or of the entire limb. Loss of muscular power, first marked, per- 
haps, in the legs, gradually comes on and extends with the features of an 
ascending paralysis. In other cases the paralysis begins in the arms. The 
extensors of the wrists and, the flexors of the ankles are early affected, so 
that there is foot and wrist drop. In severe cases there is general loss of 
muscular power, producing a flabby paralysis, which may extend to the 
muscles of the face and to the intercostals, and respiration may be carried 
on by the diaphragm alone. The muscles soften and waste rapidly. There 
may be only hyperesthesia with soreness and stiffness of the limbs; in some 
cases, increased sensitiveness with anaesthesia; in other instances the sen- 
sory disturbances are slight. The clinical picture is not to be distinguished, 
in many cases, from Landry's paralysis; in others, from the subacute mye- 
litis of Duchenne. 

The course is variable. In the most intense forms the patient may die 
in a week or ten days, with involvement of the respiratory muscles or from 
paralysis of the heart. As a rule in cases of moderate severity, after per- 
sisting for five or six weeks, the condition remains stationary and then slow 
improvement begins. The paralysis in some muscles may persist for many 
months and contractures may occur from shortening of the muscles, but 
even when this occurs the outlook is, as a rule, good, although the paralysis 
may have lasted for a year or more. 

(2) Recurring Multiple Neuritis. — Under the term polyneuritis recurrens 
Mary Sherwood has described from Eichhorsfs clinic 2 cases in adults — 
in one case involving the nerves of the right arm, in the other both legs. 
In one patient there were three attacks, in the other two, the distribution 
in the various attacks being identical. The subject has recently been fully 
discussed by H. M. Thomas (Phila. Med. Jour., 1898, i). 



* Sec under Facial Paralvsis. 



1034 



DISEASES OF THE NERVOUS SYSTEM. 



(3) Alcoholic Neuritis. — This, perhaps the most important form of mul- 
tiple neuritis, was graphically described in 1822 by James Jackson, Sr., of 
Boston. Wilks recognized it as alcoholic paraplegia, but the starting-point 
of the recent researches on the disease dates from the observations of 
Dumenil, of Rouen. Of late years our knowledge of the disease has ex- 
tended rapidly, owing to the researches of Huss, Leyden, James Ross, Buz- 
zard, and Henry Hun. It occurs most frequently in women, particularly in 
steady, quiet tipplers. Its appearance may be the first revelation to the 
physician or to the family of habits of secret drinking. The onset is usually 
gradual, and may be preceded for weeks or months by neuralgic pains and 
tingling in the feet and hands. Convulsions are not uncommon. Fever is 
rare. The paralysis gradually sets in, at first in the feet and legs, and then 
in the hands and forearms. The extensors are affected more than the flexors, 
so that there is wrist-drop and foot-drop. The paralysis may be thus lim- 
ited and not extend higher in the limbs. In other instances there is para- 
plegia alone, while in the most extreme cases all the extremities are in- 
volved. In rare instances the facial muscles and the sphincters are also 
affected. The sensory symptoms are very variable. There are cases in which 
there are numbness and tingling only, without great pain. In other cases 
there are severe burning or boring pains, the nerve trunks are sensitive, and 
the muscles are sore when grasped. The hands and feet are frequently 
swollen and congested, particularly when held down for a few moments. 
The cutaneous reflexes as a rule are preserved. The deep reflexes are usually 
lost. 

The course of these alcoholic cases is, as a rule, favorable, and after per- 
sisting for weeks or months improvement gradually begins, the muscles 
regain their power, and even in the most desperate cases recovery may 
follow. The extensors of the feet may remain paralyzed for some time, 
and give to the patient a distinctive walk, the so-called steppage gait, char- 
acteristic of peripheral neuritis. It is sometimes known as the pseudo-tabetic 
gait, although in reality it could not well be mistaken for the gait of ataxia. 
The foot is thrown forcibly forward, the toe lifted high in the air so as not 
to trip upon it. The entire foot is slapped upon the ground as a flail. 
It is an awkward, clumsy gait, and gives the patient the appearance of con- 
stantly stepping over obstacles. Among the most striking features of alco- 
holic neuritis are the mental symptoms. Delirium is common, and there 
may be hallucinations with extravagant ideas, resembling somewhat those 
of general paralysis. In some cases the picture is that of ordinary delirium 
tremens, but the most peculiar and almost characteristic mental disorder is 
that so well described by Wilks, in which the patient loses all appreciation 
of time and place, and describes with circumstantial details long journeys 
which, he says, he has recently taken, or tells of persons whom he has just 
seen. 

(4) Multiple Neuritis in the Infectious Diseases. — This has been already 
referred to, particularly in diphtheria, in which it is most common. The 
peripheral nature of the lesion in these instances has been shown by post- 
mortem examination. The outlook is usually favorable and, except in diph- 
theria, fatal cases are uncommon. Multiple neuritis in tuberculosis, dia- 



NEURITIS. 



1035 



betes, and syphilis is of the same nature, being probably due to toxic mate- 
rials absorbed into the blood. . 

(5) The Metallic Poisons. — Neuritis from arsenic may follow: (a) The 
medicinal use particularly of Fowler's solution. I have reported a case of 
Hodgkin's disease in which general neuritis was caused by § j 3 ij of the 
solution. In chorea a good many cases have been reported, (b) The acci- 
dental contamination of food or drink. Chrome yellow may be used to color 
cakes, as in the cases recorded by D. D. Stewart. A remarkable epidemic 
of neuritis occurred last year in the Midland Counties of England, which 
was traced to the use of beer containing small quantities of arsenic, a con- 
tamination from the sulphuric acid used in making glucose. Some hun- 
dreds of cases occurred. The general features have been referred to under 
arsenical poisoning. Lead is a much more frequent cause. Neuritis has 
followed the use of mercurial inunctions. Zinc is a rare cause. I saw a 
case with Dr. Urban Smith which followed the use of two grains of the 
sulpho-carbolate taken daily for three years. Tea, coffee, and tobacco are 
mentioned as rare causes. 

(6) Endemic Neuritis, Beri-beri, has been considered under the Infec- 
tious Diseases. 

Anaesthesia Paralysis. — Here perhaps may most appropriately be con- 
sidered the forms of paralysis following the use of anaesthetics, or of too 
long-continued compression during operations. Much has been written 
in the past few years upon this subject, which has been very fully consid- 
ered by Garrigues (American Journal of the Medical Sciences, 1897, i). 
There are two groups of cases: 

1. During an operation the nerves may be compressed, either the bra- 
chial plexus by the humerus or the musculo-spiral by the table. The pres- 
sure most frequently occurs when the arm is elevated alongside the head, 
as in laparotomy done in the Trendelenburg position, or held out from the 
body, as in breast amputations. Instances of paralysis of the crural nerves 
by leg-holders are also reported. The too firm application of an Esmarch 
bandage may be followed by a severe paralysis. 

2. Paralysis from cerebral lesions during etherization. In one of Gar- 
rigues' cases paralysis followed the operation, and at the autopsy, seven 
weeks later, softening of the brain was found. Apoplexy or embolism may 
develop during anaesthesia. In Montreal a cataract operation was per- 
formed on an old man. He did not recover from the anaesthetic; I found 
post mortem a cerebral haemorrhage. A man was admitted to the Phila- 
delphia Hospital, completely comatose, who on the previous day had been 
given ether for a minor operation. He never recovered consciousness, but 
remained deeply comatose, with great muscular relaxation, low tempera- 
ture, 97.5°, and noisy respirations; he died two days later. There was, 
unfortunately, no autopsy. Epileptic convulsions may occur during the 
anaesthesia, and may even prove fatal. The possibility has to be considered 
of paralysis from loss of blood in prolonged operations, though I have no 
personal knowledge of any such cases. 

And, lastly, a paralysis might result from the toxic effects of the ether 
in a very protracted administration. 



1036 



DISEASES OF THE NERVOUS SYSTEM. 



Diagnosis. — The electrical condition in multiple neuritis is thus de- 
scribed by Allen Starr: " The excitability is very rapidly and markedly 
changed; but the conditions which have been observed are quite various. 
Sometimes there is a simple diminution of excitability, and then a very 
strong faradic or galvanic current is needed to produce contractions. Fre- 
quently all faradic excitability is lost and then the muscles contract to a 
galvanic current only. In this condition it may require a very strong gal- 
vanic current to produce contraction, and thus far it is quite pathognomonic 
of neuritis. For in anterior polio-myelitis, where the muscles respond to 
galvanism only, it does not require a strong current to cause a motion until 
some months after the invasion. 

" The action of the different poles is not uniform. In many cases the 
contraction of the muscle when stimulated with the positive pole is greater 
than when stimulated with the negative pole, and the contractions may be 
sluggish. Then the reaction of degeneration is present. But in some cases 
the normal condition is found and the negative pole produces stronger 
contractions than the positive pole. A loss of faradic irritability and a 
marked decrease in the galvanic irritability of the muscle and nerve are 
therefore important symptoms of multiple neuritis." 

There is rarely any difficulty in distinguishing the alcohol cases. The 
combination of wrist and foot drop with congestion of the hands and feet, 
and the peculiar delirium already referred to, is quite characteristic. The 
rapidly advancing cases with paralysis of all extremities, often reaching 
to the face and involving the sphincters, are more commonly regarded as 
of spinal origin, but the general opinion seems to point strongly to the 
fact that all such cases are peripheral. The less acute cases, in which the 
paralysis gradually involves the legs and arms with rapid wasting, simu- 
late closely and are usually confounded with the subacute atrophic spinal 
paralysis of Duchenne. The diagnosis from locomotor ataxia is rarely 
difficult. The steppage gait is entirely different from that of tabes. There 
is rarely positive incoordination. The patient can usually stand well with 
the eyes closed. Foot-drop is not common in locomotor ataxia. The light- 
ning pains are absent and there are no pupillary symptoms. The etiology, 
too, is of moment. The patient is recovering from a paralysis which has 
been more extensive, or from arsenical poisoning, or he has diabetes. 

Treatment.' — Best in bed is essential. In the acute cases with fever, 
the salicylates and antipyrin are recommended. To allay the intense pain 
morphia or the hot applications of lead water and laudanum are often 
required. Great care must be exercised in treating the alcoholic form, 
and the physician must not allow himself to be deceived by the statements 
of the relatives. It is sometimes exceedingly difficult to get a history of 
spirit-drinking. In the alcoholic form it is well to reduce the stimulants 
gradually. If there is any tendency to bed-sores an air-bed should be used 
or the patient placed in a continuous bath. Gentle friction of the mus- 
cles may be applied from the outset, and in the later stages, when the atro- 
phy is marked and the pains have lessened, massage is probably the most 
reliable means at our command. Contractures may be gradually overcome 
by passive movements and extension. Often, with the most extreme de- 



NEUROMATA. 



1037 



formity from contracture, recovery is, in time, still possible. The inter- 
rupted current is useful when the acute stage is passed. 

Of internal remedies, strychnia is of value and may be given in in- 
creasing doses. Arsenic also may be employed, and if there is a history of 
syphilis the iodide of potassium and mercury may be given. 

II. NEUROMATA. 

Tumors situated on nerve fibres may consist of nerve substance proper, 
the true neuromata, or of fibrous tissue, the false neuromata. The true 
neuroma usually contains nerve fibres only, or in rare instances ganglion 
cells. Cases of ganglionic or medullary neuroma are extremely rare; some 
of them, as Lancereaux suggests, are undoubtedly instances of malforma- 
tion of the brain substance. In other instances, as in the case which I 
reported, the tumor is, in all probability, a glioma with cells closely resem- 
bling those of the central nervous system. The true fascicular neuroma 
occurs in the form of the small subcutaneous painful tumor — tubercula 
dolorosa — which is situated on the nerves of the skin about the joints, some- 
times on the face or on the breast. It is not always made up of nerve fibres, 
but may be, as shown by Hoggan, an adenomatous growth of the sweat 
glands. 

The true neuromata, as a rule, are not painful, and occasionally are 
found associated with the nerve fibres in various regions. Those which 
develop at the ends and along the course of the nerves of the stump after 
amputation consist of connective tissue and of medullated and non-mednl- 
lated nerve fibres. The most remarkable form is the plexiform neuroma, 
in which the various nerve cords are occupied by many hundreds of tumors. 
The cases are usually congenital. The tumors occur in all the nerves of 
the body. One of the most remarkable is that described by Prudden, the 
specimens of which are in the medical museum of Columbia College, New 
York. There were over 1,182 distinct tumors distributed on the nerves 
of the body. E. W. Smith's splendid monograph on neuromata has been 
reprinted this year (1898) by the New Sydenham Society. 

Neuromata rarely cause symptoms, except the subcutaneous painful 
tumor or those in the amputation stump. Here they may be very painful 
and cause great distress. Motor symptoms are sometimes present, particu- 
larly a constant twitching. Epilepsy has sometimes been associated, and 
relief has followed removal of the growths. 

The only available treatment is excision. The subcutaneous painful 
tumor does not return, and excision completely relieves the symptoms. On 
the other hand, the amputation neuromata may recur. 



65 



1038 



DISEASES OF THE NERVOUS SYSTEM. 



III. DISEASES OF THE CEREBRAL NERVES. 

Olfactory Nerves and Tracts 

The functions of the olfactory nerves may be disturbed at their origin, 
in the nasal mucous membrane, at the bulb, in the course of the tract, or 
at the centres in the brain. The disturbances may be manifested in sub- 
jective sensations of smell, complete loss of the sense, and occasionally in 
hyperesthesia. 

(a) Subjective Sensations; Parosmia. — Hallucinations of this kind are 
found in the insane and in epilepsy. The aura may be represented by an 
unpleasant odor, described as resembling chloride of lime, burning rags, 
or feathers. In a few cases with these subjective sensations tumors have 
been found in the hippocampi. In rare instances, after injury of the head 
the sense is perverted — odors of the most different character may be alike, 
or the odor may be changed, as in a patient noted by Morell Mackenzie, 
who for some time could not touch cooked meat, as it smelt to her exactly 
like stinking fish. 

(b) Increased sensitiveness, or Tiyperosmia, occurs chiefly in nervous, hys- 
terical women, in whom it may sometimes be developed so greatly that, like 
a dog, they can recognize the difference between individuals by the odor 
alone. 

(c) Anosmia; Loss of the Sense of Smell. — This may be produced by: 
(1) Affections of the origin of the nerves in the mucous membrane, which 
is perhaps the most frequent cause. It is by no means uncommon in asso- 
ciation with chronic nasal catarrh and polypi. In paralysis of the fifth 
nerve, the sense of smell may be lost on the affected side, owing to inter- 
ference with the secretion. 

It is doubtful whether the cases of loss of smell following the inhala- 
tions of very foul or strong odors should come under this or under the 
central division. 

(2) The lesions of the bulbs or of the tracts. In falls or blows, in caries 
of the bones, and in meningitis or tumor, the bulbs or the olfactory tracts 
may be involved. After an injury to the head the loss of smell may be the 
only symptom. Mackenzie notes a case of a surgeon who was thrown from 
his gig and lighted on his head. The injury was slight, but the anosmia 
which followed was persistent. In locomotor ataxia the sense of smell may 
be lost, possibly owing to atrophy of the nerves. 

(3) Lesions of the olfactory centres. There are congenital cases in 
which the structures have not been developed. Cases have been reported 
by Beevor, Hughlings Jackson, and others, in which anosmia has been 
associated with disease in the hemisphere. The centre for the sense of 
smell is placed by Ferrier in the uncinate gyrus. Flechsig describes (1) a 
frontal centre in the base of the frontal lobe and (2) a temporal centre in 
the uncus. 

To test the sense of smell the pungent bodies, such as ammonia, which 
act upon the fifth nerve, should not be used, but such substances as cloves, 
peppermint, and musk. This sense is readily tested as a routine matter in 



DISEASES OF THE CEREBRAL NERVES. 



1039 



brain cases by having two or three bottles containing the essential oils. 
In all instances a rhinoscopical examination should be made, as the con- 
dition may be due to local, not central causes. The treatment is unsatisfac- 
tory even in the cases due to local lesions in the nostrils. 

Optic Nerve and Tract. 

(1) Lesions of the Retina. 

These are of importance to the physician, and information of the great- 
est value may be obtained by a systematic examination of the eye-grounds. 
Only a brief reference can here be made to the more important of the ap- 
pearances. 

(a) Retinitis. — This occurs in certain general affections, more particu- 
larly in Bright's disease, syphilis, leukaemia, and anaemia. The common 
feature in all these states is the occurrence of haemorrhage and the develop- 
ment of opacities. There may also be a diffuse cloudiness due to effusion 
of serum. The haemorrhages are in the layer of nerve fibres. They vary 
greatly in size and form, but often follow the course of vessels. When 
recent the color is bright red, but they gradually change and old haemor- 
rhages are almost black. The white spots are due either to fibrinous exudate 
or to fatty degeneration of the retinal elements, and occasionally to accumu- 
lation of leucocytes or to a localized sclerosis of the retinal elements. The 
more important of the forms of retinitis to be recognized are: 

Albuminuric retinitis, which occurs in chronic nephritis, particularly in 
the interstitial or contracted form. The percentage of cases affected is from 
15 to 25. There are instances in which these retinal changes are associated 
with the granular kidney at a stage when the amount of albumen may be 
slight or transient; but in all such instances it will be found that there 
is a marked arterio-sclerosis. Gowers recognizes a degenerative form (most 
common), in which, with the retinal changes, there may be scarcely any 
alteration in the disk; a hemorrhagic form, with many haemorrhages and 
but slight signs of inflammation; and an inflammatory form, in which 
there is much swelling of the retina and obscuration of the disk. It is note- 
worthy that in some instances the inflammation of the optic nerve pre- 
dominates over the retinal changes, and one may be in doubt for a time 
whether the condition is really associated with the renal changes or de- 
pendent upon intracranial disease. 

Syphilitic Retinitis. — In the acquired form this is less common than 
choroiditis. In inherited syphilis retinitis pigmentosa is sometimes met 
with. 

Retinitis in Anwmia. — It has long been known that a patient may 
become blind after a large haemorrhage, either suddenly or within two or 
three days, and in one or both eyes. Occasionally the loss may be perma- 
nent and complete. In some of these instances a neuro-retinitis lias been 
found, probably sufficient to account for the symptoms. In the more 
chronic anaemias, particularly in the pernicious form, retinitis is common, 
as determined first by Quincke. 

In malaria retinitis or neuro-retinitis may be present, as noted by 



1040 



DISEASES OF THE NERVOUS SYSTEM. 



Stephen Mackenzie. It is seen only in the chronic cases with anaemia, and 
in my experience is not nearly so common proportionately as in pernicious 
anaemia. 

Leukemic Retinitis. — In this affection the retinal veins are large and 
distended; there is also a peculiar retinitis, as described by Liebreieh. It 
is not very common. It existed in only 3 of 10 cases of which I have notes 
of examination of the retina. There are numerous haemorrhages and white 
or yellow areas, which may be large and prominent. In one of my cases 
the retina post mortem was dotted with many small, opaque, white spots, 
looking like little tumors, the larger of which had a diameter of nearly 
2 mm. In Case 13 of my series the leukaemia was diagnosed by Norris and 
De Schweinitz, at whose clinic the patient had applied on account of failing 
vision, from the condition of the eye-grounds alone. 

Eetinitis is also found occasionally in diabetes, in purpura, in chronic 
lead poisoning, and sometimes as an idiopathic affection. 

(b) Functional Disturbances of Vision— (1) Toxic Amaurosis. — This 
occurs in uraemia and may follow convulsions or come on independently. 
The condition, as a rule, persists only for a day or two. This foim of 
amaurosis occurs in poisoning by lead, alcohol, and occasionally by quinine. 
It seems more probable that the poisons act on the centres and not on the 
retina. 

(2) Tobacco Amblyopia. — The loss of sight is usually gradual, equal in 
both eyes, and affects particularly the centre of the field of vision. The 
eye-grounds may be normal, but occasionally there is congestion of the 
disks. On testing the color fields a central scotoma for red and green is 
found in all cases. Ultimately, if the use of tobacco is continued, organic 
changes may develop with atrophy of the disk. 

(3) Hysterical Amaurosis. — More frequently this is loss of acuteness 
of vision — amblyopia — but the loss of sight in one or both eyes may ap- 
parently be complete. The condition will be mentioned subsequently under 
hysteria. 

(4) Night-blindness — nyctalopia — the condition in which objects are 
clearly seen during the day or by strong artificial light, but become invisible 
in the shade or in twilight, and hemeralopia, in which objects cannot be 
clearly seen without distress in daylight or in a strong artificial light, but 
are readily seen in a deep shade or in twilight, are functional anomalies of 
vision which rarely come under the notice of the physician. It may occur 
in epidemic form. 

(5) Retinal hyperesthesia is sometimes seen in hysterical women, but 
is not found frequently in actual retinitis. I have seen it once, however, 
in albuminuric retinitis, and once, in a marked degree, in a patient with 
aortic insufficiency, in whose retinae there were no signs other than the 
throbbing arteries. 

(2) Lesions of the Optic Nerve. 

(a) Optic Neuritis (Papillitis; Choked Dish). — In the first stage there 
is congestion of the disk and the edges are blurred and striated. In the 
second stage, the congestion is more marked, the swelling increases, the 



DISEASES OF THE CEREBRAL NERVES. 



1041 



striation also is more visible. The physiological cupping disappears and 
haemorrhages are not uncommon. The arteries present little change, the 
veins are dilated, and the disk may swell greatly. In slight grades of in- 
flammation the swelling gradually subsides and occasionally the nerve re- 
covers completely. In instances in which the swelling and exudate are 
very great, the subsidence is slow, and when it finally disappears there is 
complete atrophy of the nerve. The retina not infrequently participates 
in the inflammation, which is then a neuro-retinitis. 

This condition is of the greatest importance in diagnosis. It may exist 
in its early stages without any disturbance of vision, and even with exten- 
sive papillitis the sight may for a time be good. 

Optic neuritis is seen occasionally in anaemia and lead poisoning, more 
commonly in Bright' s disease as neuro-retinitis. It occurs occasionally as 
a primary idiopathic affection. The frequent connection with intracranial 
disease, particularly tumor, makes its presence of great value to practi- 
tioners. The nature of the growth is without influence. In over 90 per 
cent of such instances the papillitis is bilateral. It is also found in menin- 
gitis, either the tuberculous or the simple form. In meningitis it is easy 
to see how the inflammation may extend down the nerve sheath. In the 
case of tumor it was thought at first that a choked disk resulted from in- 
creased pressure within the skull. It is now more commonly regarded, 
however, as a descending neuritis. 

(b) Optic Atrophy. — This may be: (1) A primary affection. There is 
an hereditary form, in which the disease has developed in all the males of 
a family shortly after puberty. A large number of the cases of primary 
atrophy are associated with spinal disease, particularly locomotor ataxia. 
Other causes which have been assigned for the primary atrophy are cold, 
sexual excesses, diabetes, the specific fevers, alcohol, and lead. 

(2) Secondary atrophy results from cerebral diseases, pressure on the 
chiasma or on the nerves, or, most commonly of all, as a sequence of pa- 
pillitis. 

The ophthalmoscopic appearances are different in the cases of primary 
and secondary atrophy. In the former, the disk has a gray tint, the edges 
are well defined, and the arteries look almost normal; whereas in the con- 
secutive atrophy the disk has a staring opaque-white aspect, with irregular 
outlines, and the arteries are very small. 

The symptom of optic atrophy is loss of sight, proportionate to the 
damage in the nerve. The change is in three directions: " (1) Diminished 
acuity of vision; (2) alteration in the field of vision; and (3) altered per- 
ception of color " (Gowers). The outlook in primary atrophy is bad. 

(3) Affections of the Chiasma and Tract. 

At the chiasma the optic nerves undergo partial decussation. Each 
optic tract, as it leaves the chiasma, contains nerve fibres which originate 
in the retinae of both eyes. Thus, of the fibres of the right trad, pari have 
come through the chiasma without decussating from the temporal half 
of the right retina, the other and larger portion of the fibres of the tract 



1042 



DISEASES OF THE NERVOUS SYSTEM. 



have decussated in the chiasma, coming as they do from the left optic nerve 
and the nasal half of the retina on the left side. The fibres which cross 
are in the middle portion of the chiasma, while the direct fibres are on each 
side. The following are the most important changes which ensue in lesions 
of the tract and of the chiasma: 

(a) Unilateral Affection of Tract. — If on the right side, this produces 
loss of function in the temporal half of the retina on the right side, and in 
the nasal half of the retina on the left side, so that there is only half vision, 
and the patient is blind to objects on the left side. This is termed homony- 
mous hemianopia or lateral hemianopia. The fibres passing to the right 
half of each retina being involved, the patient is blind to objects in the 
left half of each visual field. The hemianopia may be partial and only a 
portion of the half field may be lost. The unaffected visual fields may have 
the normal extent, but in some instances there is considerable reduction. 
When the left half of one field and the right half of the other, or vice versa, 
are blind, the condition is known as heteronymous hemianopia. 

(o) Disease of the Chiasma. — (1) A lesion involves, as a rule, chiefly 
the central portion, in which the decussating fibres pass which supply the 
inner or nasal halves of the retinas, producing in consequence loss of vision 
in the outer half of each field, or what is known as temporal hemianopia. 

(2) If the lesion is more extensive it may involve not only the central 
portion, but also the direct fibres on one side of the commissure, in which 
case there would be total blindness in one eye and temporal hemianopia 
in the other. 

(3) Still more extensive disease is not infrequent from pressure of tu- 
mors in this region, the whole chiasma is involved, and total blindness 
results. The different stages in the process may often be traced in a single 
case from temporal hemianopia, then complete blindness in one eye with 
temporal hemianopia in the other, and finally complete blindness. 

(4) A limited lesion of the outer part of the chiasma involves only the 
direct fibres passing to the temporal halves of the retinas and inducing 
blindness in the nasal field, or, as it is called, nasal hemianopia. This, of 
course, is extremely rare. Double nasal hemianopia may occur as a mani- 
festation of tabes and in tumors involving the outer fibres of each tract. 

(4) Affections of the Tract and Centres. 

The optic tract crosses the cms (cerebral peduncle) to the hinder part 
of the optic thalamus and divides into two portions, one of which (the 
lateral root) goes to the pulvinar of the thalamus, the lateral geniculate 
body, and to the anterior quadrigeminal body (superior colliculus). From 
these parts, in which the lateral root terminates, fibres pass into the pos- 
terior part of the internal capsule and enter the occipital lobe, forming the 
fibres of the optic radiation, which terminate in and about the cuneiis, the 
region of the visual perceptive centre. The fibres of the medial division of 
the tract pass to the medial geniculate body and to the posterior quadri- 
geminal body. The medial root contains the fibres of the commissura in- 
ferior of v. G-udden, which are believed to have no connection with the 



DISEASES OF THE CEREBRAL NERVES. 



1043 



CUNEUS 




Fig. 11. — Diagram of visual paths. (From Vialet, modified.) OP. N., Optic nerve. 
OP. C, Optic chiasm. OP. T., Optic tract. OP. R., Optic radiations. GEN., Genic- 
ulate body. THO., Optic thalamus. C. QU., Corpora quadrigemina. C. C, Corpus 
callosum. V. S., Visual speech centre. A. S., Auditory speech centre. M. S., Motor 
speech centre. A lesion at 1 causes blindness of that eye ; at 2, bi-temporal hemia- 
nopia ; at 3, nasal hemianopia. Symmetrical lesions at 3 and 3' would cause bi-nasal 
hemianopia; at 4, hemianopia of both eyes, with hemianopic pupillary inaction; at 
5 and 6, hemianopia of both eyes, pupillary reflexes normal ; at 7, amblyopia, espe- 
cially of opposite eye ; at 8, on left side, word-blindness. 



1044 



DISEASES OF THE NERVOUS SYSTEM. 



retina. It is still held by some physiologists that the cortical visual centre 
is not confined to the occipital lobe alone, bnt embraces the occipito-angular 
region. 

A lesion of the fibres of the optic path anywhere between the cortical 
centre and the chiasma will produce hemianopia. The lesion may be situ- 
ated: (a) In the optic tract itself. (5) In the region of the thalamus, 
lateral geniculate body, and the corpora quadrigemina, into which the 
larger part of each tract enters, (c) A lesion of the fibres passing from the 
centres just mentioned to the occipital lobe. This may be either in the 
hinder part of the internal capsule or the white fibres of the optic radiation. 
(d) Lesion of the cuneus. Bilateral disease of the cuneus may result in 
total blindness, (e) There is clinical evidence to show that lesion of the an- 
gular gyrus may be associated with visual defect, not so often hemianopia 
as crossed amblyopia, dimness of vision in the opposite eye, and great con- 
traction in the field of vision. Lesions in this region are associated with 
mind blindness, a condition in which there is 'failure to recognize the nature 
of objects. 

The effects of lesions in the optic nerve in different situations from the 
retinal expansion to the brain cortex are as follows: (1) Of the optic nerve 
— total blindness of the corresponding eye; (2) of the optic chiasma, either 
temporal hemianopia, if the central part alone is involved, or nasal hemi- 
anopia, if the lateral region of each chiasma is involved; (3) lesion of the 
optic tract between the chiasma and the lateral geniculate body, pro- 
duces lateral hemianopia; (4) lesion of the central fibres of the nerve be- 
tween the geniculate bodies and the cerebral cortex produces lateral hemi- 
anopia; (5) lesion of the cuneus causes lateral hemianopia; and (6) lesion 
of the angular gyrus may be associated with hemianopia, sometimes crossed 
amblyopia, and the condition known as mind blindness. (See Fig. 11, with 
accompanying explanation.) 

Diagnosis. — The student or practitioner must have a clear idea of 
the physiology of the nerve centres before he can appreciate the symptoms 
or undertake the diagnosis of lesions of the optic nerve. Having deter- 
mined the presence of hemianopia, the question arises as to the situation 
of the lesion, whether in the tract between the chiasma and the geniculate 
bodies or in the central portion of the fibres between these bodies and the 
visual centres. This can be determined in some cases by the test known 
as Wernicke's Jiemiopic pupillary inaction. The pupil reflex depends on 
the integrity of the retina or receiving membrane, on the fibres of the op- 
tic nerve and tract which transmit the impulse, and the nerve centre at 
the termination of the optic tract which receives the impression and trans- 
mits it to the third nerve along which the motor impulses pass to the iris. 
If a bright light is thrown into the eye and the pupil reacts, the integrity 
of this reflex arc is demonstrated. It is possible in cases of lateral hemi- 
anopia so to throw the light into the eye that it falls upon the blind half 
of the retina. If when this is done the pupil contracts, the indication is 
that the reflex arc above referred to is perfect, by which we mean that the 
optic nerve fibres from the retinal expansion to the centre, the centre 
itself, and the third nerve are uninvolved. In such a case the conclusion 



DISEASES OP THE CEREBRAL NERVES. 



1045 



would be justified that the cause of the hemianopia was central; that is, 
situated beyond the geniculate body, either in the fibres of the optic radi- 
ation or in the visual cortical centres. If, on the other hand, when the 
light is carefully thrown on the hemiopic half of the retina, the pupil re- 
mains inactive, the conclusion is justifiable that there is interruption in the 
path between the retina and the nucleus of the third nerve, and that the 
hemianopia is not central, but dependent upon a lesion situated in the optic 
tract. This test of Wernicke's is sometimes difficult to obtain. It is best 
performed as follows : " The patient being in a dark or nearly dark room 
with the lamp or gas-light behind his head in the usual position, I bid him 
look over to the other side of the room, so as to exclude accommodative 
iris movements (which are not necessarily associated with the reflex). Then 
I throw a faint light from a plane mirror or from a large concave mirror, 
held well out of focus, upon the eye and note the size of the pupil. With 
my other hand I now throw a beam of light, focussed from the lamp by an 
ophthalmoscopic mirror, directly into the optical centre of the eye; then 
laterally in various positions, and also from above and below the equator 
of the eye, noting the reaction at all angles of incidence of the ray of light." 
(Seguin.) 

The significance of hemianopia varies. There is a functional hemi- 
anopia associated with migraine and hysteria. In a considerable propor- 
tion of all cases there are signs of organic brain-disease. In a certain num- 
ber of instances of slight lesions of the occipital lobe hemiachromatopsia 
has been observed. The homonymous halves of the retina as far as the 
fixation point are dulled, or blind for colors. Hemiplegia is common, in 
which event the loss of power and blindness are on the same side. Thus, 
a lesion in the left hemisphere involving the motor tract produces right 
hemiplegia, and when the fibres of the optic radiation are involved in the 
internal capsule, there is also lateral hemianopia, so that objects in the field 
of vision to the right are not perceived. Hemiangesthesia is not uncommon 
in such cases, owing to the close association of the sensory and visual tracts 
at the posterior part of the internal capsule. Certain forms of aphasia 
also occur in many of the cases. 

The optic aphasia of Freund may be mentioned here. The patient after 
an apoplectic attack, though able to recognize ordinary objects shown to 
him is unable to name them correctly. If he' be permitted to touch the 
object he may be able to name it quickly and correctly. Freund's optic 
aphasia differs from mind-blindness, since in the latter affection the objects 
seen are not recognized. Optic aphasia, like»word-blindness, never occurs 
alone, but is always associated with hemianopia, or mind-blindness, and 
often also with word-deafness. In the cases which have thus far come to 
autopsy there has always been a lesion in the white matter of the occipital 
lobe on the left side. 

Motor Neryks ok the Eyeball. 

Third Nerve (Nervus oculomotor in s). — The nucleus of origin of this 
nerve is situated in the floor of the aqueduct of Sylvius; the nerve passes 



1046 



DISEASES OF THE NEEVOUS SYSTEM. 



through the cms at the side of which it emerges. Passing along the wall 
of the cavernous sinus, it enters the orbit through the sphenoidal fissure 
and supplies, by its superior branch, the levator palpebrse superioris and 
the superior rectus, and by its inferior branch the internal and inferior 
recti muscles and the inferior oblique. Branches pass to the ciliary muscle 
and the constrictor of the iris. Lesions may affect the nucleus or the nerve 
in its course and cause either paralysis or spasm. 

Paralysis. — A nuclear lesion is usually associated with the disease of 
the centres for the other eye muscles, producing a condition of general oph- 
thalmoplegia. More commonly the nerve itself is involved in its course, 
either by meningitis, gummata, or aneurism, or is attacked by a neuritis, as 
in diphtheria and locomotor ataxia. Complete paralysis of the third nerve 
is accompanied by the following symptoms: 

Paralysis of all the muscles, except the superior oblique and external 
rectus, by which the eye can be moved outward and a little downward and 
inward. There is divergent strabismus. There is ptosis or drooping of 
the upper eyelid, owing to paralysis of the levator palpebral The pupil is 
usually dilated. It does not contract to light, and the power of accom- 
modation is lost. The most striking features of this paralysis are the 
external strabismus, with diplopia or double vision, and the ptosis. In 
very many cases the affection of the third nerve is partial. Thus the 
levator palpebral and the superior rectus may be involved together, or the 
ciliary muscles and the iris may be affected and the external muscles may 
escape. 

There is a remarkable form of recurring oculo-motor paralysis affect- 
ing chiefly women, and involving all the branches of the nerve. In some 
cases the attacks have come on at intervals of a month; in others a much 
longer period has elapsed. The attacks may persist throughout life. They 
are sometimes associated with pain in the head and sometimes with mi- 
graine. Mary Sherwood has collected from the literature 23 cases. 

Ptosis is a common and important symptom in nervous affections. We 
may here briefly refer to the conditions under which it may occur: (a) A 
congenital, incurable form, which is frequently seen; (b) the form associ- 
ated with definite lesion of the third nerve, either in its course or at its 
nucleus. This may come on with paralysis of the superior rectus alone or 
with paralysis of the internal and inferior recti as well, (c) There are 
instances of complete or partial ptosis associated with cerebral lesions with- 
out any other branch of the third nerve being paralyzed. The exact po- 
sition of the cortical centre ©r centres is as yet unknown, (d) Hysterical 
ptosis, which is double and occurs with other hysterical symptoms, (e) 
Pseudo-ptosis, due to affection of the sympathetic nerve, is associated with 
symptoms of vaso-motor palsy, such as elevation of the temperature on the 
affected side with redness and oedema of the skin. Contraction of the pupil 
exists on the same side and the eyeball appears rather to have shrunk into 
the orbit. (/) In idiopathic muscular atrophy, when the face muscles are 
involved, there may be marked bilateral ptosis. And, lastly, in weak, deli- 
cate women there is often to be seen a transient ptosis, particularly in the 
morning. 



DISEASES OF THE CEREBRAL NERVES. 



1047 



Among the most important of the symptoms of the third-nerve paraly- 
sis are those which relate to the ciliary muscle and iris. 

Cycloplegia, paralysis of the ciliary muscle, causes loss of the power of 
accommodation. Distant vision is clear, but near objects cannot be prop- 
erly seen. In consequence the vision is indistinct, but can be restored by 
the use of convex glasses. This may occur in one or in both eyes; in the 
latter case it is usually associated with disease in the nuclei of the nerve. 
Cycloplegia is an early and frequent symptom in diphtheritic paralysis and 
occurs also in tabes. 

Iridoplegia, or paralysis of the iris, occurs in three forms (Gowers). 

(a) Accommodative iridoplegia, in which the pupil does not diminish in 
size during the act of accommodation. To test for this the patient should 
look first at a distant and then at a near object in the same line of vision. 

(b) Reflex Iridoplegia. — The path for the iris reflex is along the optic 
nerve and tract to its termination, then to the nucleus of the third nerve, 
and along the trunk of this nerve to the ciliary ganglion, and so through 
the ciliary nerves to the eyes. Each eye should be tested separately, the 
other one being covered. The patient should look at a distant object in a 
dark part of the room; then a light is brought suddenly in front of the 
eye at a distance of three or four feet, so as to avoid the effect of accommo- 
dation. Loss of this iris reflex with retention of the accommodation con- 
traction is known as the Argyll Eobertson pupil. 

(c) Loss of the Skin Reflex. — If the skin of the neck is pinched or 
pricked the pupil dilates reflexly, the afferent impulses being conveyed 
along the cervical sympathetic. Erb pointed out that this skin reflex is 
lost usually in association with the reflex contraction, but the two are not 
necessarily conjoined. In iridoplegia the pupils are often small, particu- 
larly in spinal disease, as in the characteristic small pupils of tabes — spinal 
myosis. Iridoplegia may coexist with a pupil of medium size. 

Inequality of the pupils — anisocoria — is not infrequent in progressive 
paresis and in tabes. It may also occur in perfectly healthy individuals. 

Spasm. — Occasionally in meningitis and in hysteria there is spasm of 
the muscles supplied by the third nerve, particularly the internal rectus 
and the levator palpebral The clonic rhythmical spasm of the eye muscles 
is known as nystagmus, in which there is usually a bilateral, rhythmical, 
involuntary movement of the eyeballs. The condition is met with in many 
congenital and acquired brain lesions, in albinism, and sometimes in coal- 
miners. 

Fourth Nerve (Nervus trochlearis). — This supplies the superior oblique 
muscle. In its course around the outer surface of the cms and in its 
passage into the orbit it is liable to be compressed by tumors, by aneurism, 
or in the exudation of basilar meningitis. Its nucleus in the upper part 
of the fourth ventricle may be involved by tumors or undergo degeneration 
with the other ocular nuclei. The superior oblique muscle acts in such a 
way as to direct the eyeball downward and rotates it slightly. The paralysis 
causes defective downward and inward movement, often too slight to be 



1048 



DISEASES OF THE NERVOUS SYSTEM. 



noticed. The head is inclined somewhat forward and toward the sound 
side, and there is double vision when the patient looks down. 

Sixth Nerve (Nervus abducens). — This nerve emerges at the junction of 
the pons and medulla, then, passing forward, it enters the orbit and sup- 
plies the external rectus muscle. It is affected by meningitis at the base, 
by gummata or other tumors, and sometimes by cold. There is internal 
strabismus, and the eye cannot be turned outward. Diplopia occurs on 
looking toward the paralyzed side. 

" When the nucleus is affected there is, in addition to paralysis of the 
external rectus, inability of the internal rectus of the opposite eye to turn that 
eye inward. As a consequence of this the axes of the eyes are kept parallel 
and both are conjugately deviated to the opposite side, away from the side 
of lesion. The reason of this is that the nucleus of the sixth nerve sends 
fibres up in the pons to that part of the nucleus of the opposite third 
nerve which supplies the internal rectus. We thus have paralysis of the 
internal rectus without the nucleus of the third nerve being involved, 
owing to its receiving its nervous impulses for parallel movement from 
the sixth nucleus of the opposite side. As the sixth nucleus is in such 
proximity to the facial nerve in the substance of the pons, it is frequently 
found that the whole of the face on the same side is paralyzed, and gives 
the electrical reaction of degeneration, so that with a lesion of the left 
sixth nucleus there is conjugate deviation of both eyes to the right — i. e., 
paralysis of the left external and the right internal rectus, and sometimes 
complete paralysis of the left side of the face " (Beevor). 

General Features of Paralysis of the Motor Nerves of the Eye. — Gowers 
divides them into five groups: 

(a) Limitation of Movement. — Thus, in paralysis of the external rectus, 
the eyeball cannot be moved outward. When the paralysis is incomplete 
the movement is deficient in proportion to the degree of the palsy. 

(b) Strabismus. — The axes of the eyes do not correspond. Thus, pa- 
ralysis of the internal rectus causes a divergent squint; of the external 
rectus, a convergent squint. At first this is only evident when the eyes are 
moved in the direction of the action of the weak muscle, but may become 
constant by the contraction of the opposing muscle. The deviation of the 
axis of the affected eye from parallelism with the other is called the pri^ 
mary deviation. 

(c) Secondary Deviation. — If, while the patient is looking at an ob- 
ject, the sound eye is covered, so that he fixes the object looked at with 
the affected eye only, the sound eye is moved still further in the same di- 
rection — e. g., outward — with paralysis of the opposite internal rectus. 
This is known as secondary deviation. It depends upon the fact that, if 
two muscles are acting together, when one is weak and an effort is made 
to contract it, the increased effort — innervation — acts powerfully upon the 
other muscle, causing an increased contraction. 

(d) Erroneous Projection. — " We judge of the relation of external ob- 
jects to each other by the relation of their images on the retina; but we 
judge of their relation to our own body by the position of the eyeball 



DISEASES OF THE CEREBRAL NERVES. 



1049 



as indicated to us by the innervation we give to the ocular muscles " 
(Gowers). With the eyes at rest in the mid-position, an object at which 
we are looking is directly opposite our face. Turning the eyes to one 
side, we recognize that object in the middle of the field or to the side of 
this former position. We estimate the degree by the amount of movement 
of the eyes, and when the object moves and we follow it we judge of its 
position by the amount of movement of the eyeballs. When one ocular 
muscle is weak, the increased innervation gives the impression of a greater 
movement of the eye than has really taken place. The mind, at the same 
time, receives the idea that the object is further on one side than it really 
is, and in an attempt to touch it the finger may go beyond it. As the 
equilibrium of the body is in a large part maintained by a knowledge of 
the relation of external objects to it obtained by the action of the eye mus- 
cles, this erroneous projection resulting from paralysis disturbs the har- 
mony of these visual impressions and may lead to giddiness — ocular vertigo. 

(e) Double Vision. — This is one of the most disturbing features of 
paralysis of the eye muscles. The visual axes do not correspond, so that 
there is a double image — diplopia. That seen by the sound eye is termed 
the true image; that by the paralyzed eye, the false. In simple or homon- 
ymous diplopia the false image is " on the same side of the other as the eye 
by which it is seen." In crossed diplopia it is on the other side. In con- 
vergent squint the diplopia is simple; in divergent it is crossed. 

Ophthalmoplegia. — Under this term is described a chronic progressive 
paralysis of the ocular muscles. Two forms are recognized — ophthalmo- 
plegia externa and ophthalmoplegia interna. The conditions may occur 
separately or together and are described by Gowers under nuclear ocular 
palsy. 

Ophthalmoplegia externa. — The condition is one of more or less com- 
plete palsy of the external muscles of the eyeball, due usually to a slow 
degeneration in the nuclei of the nerves, but sometimes to pressure of 
tumors or to basilar meningitis. It is often, but not necessarily, associated 
with ophthalmoplegia interna. Siemerling, in a monograph on the sub- 
ject, states that 62 cases are on record. In only 11 of these could syphilis 
be positively determined. The levator muscles of the eyelids and the 
superior recti are first involved, and gradually the other muscles, so that 
the eyeballs are fixed and the eyelids droop. There is sometimes slight 
protrusion of the eyeballs. The disease is essentially chronic and may last 
for many years. It is found particularly in association with general paraly- 
sis, locomotor ataxia, and in progressive muscular atrophy. Mental dis- 
orders were present in 11 of the 62 cases. With it may be associated 
atrophy of the optic nerve and affections of other cerebral nerves. Occa- 
sionally, as noted by Bristowe, it may be functional. 

Ophthalmoplegia interna. — Jonathan Hutchinson applied this term to 
a progressive paralysis of the internal ocular muscles, causing loss of pupil- 
lary action and the power of accommodation. When the internal and ex- 
ternal muscles are involved the affection is known as total ophthalmoplegia, 
and in a majority of the cases the two conditions are associated. In some 
instances the internal form may depend upon disease of the ciliary ganglion. 



1050 



DISEASES OP THE NERVOUS SYSTEM. 



While, as a rule, ophthalmoplegia is a chronic process, there is an acute 
form associated with haemorrhagie softening of the nuclei of the ocular 
muscles. There is usually marked cerehral disturbance. It was to this 
form that Wernicke gave the name polio-encephalitis superior. 

Treatment of Ocular Palsies. — It is important to ascertain, if 
possible, the cause. The forms associated with locomotor ataxia are ob- 
stinate, and resist treatment. Occasionally, however, a palsy, complete or 
partial, may pass away spontaneously. The group of cases associated with 
chronic degenerative changes, as in progressive paresis and bulbar paraly- 
sis, is little affected by treatment. On the other hand, in syphilitic cases, 
mercury and iodide of potassium are indicated and are often beneficial. 
Arsenic and strychnia, the latter hypodermically, may be employed. In 
any case in which the onset is acute, with pain, hot fomentations and coun- 
ter-irritation or leeches applied to the temple give relief. The direct treat- 
ment by electricity has been extensively employed, but probably without 
any special effect. The diplopia may be relieved by the use of prisms, or 
it may be necessary to cover the affected eye with an opaque glass. 

Fifth Neeve (Nervus trigeminus). 

Paralysis may result from: (a) Disease of the pons, particularly haem- 
orrhage or patches of sclerosis. (&) Injury or disease at the base of the 
brain. Fracture rarely involves the nerve; on the other hand, meningitis, 
acute or chronic, and caries of the bone are not uncommon causes, (c) 
The branches may be affected as they pass out — the first division by tumors 
pressing on the cavernous sinus or by aneurism; the second and third 
divisions by growths which invade the spheno-maxillary fossa, (d) Pri- 
mary neuritis, which is rare. 

Symptoms. — (a) Sensory Portion. — Disease of the fifth nerve may 
cause loss of sensation in the parts supplied, including the half of the face, 
the corresponding side of the head, the conjunctiva, the mucosa of the lips, 
tongue, hard and soft palate, and of the nose of the same side. The 
anaesthesia may be preceded by tingling or pain. The muscles of the face 
are also insensible and the movements may be slower. The sense of smell 
is interfered with. There is disturbance of the sense of taste. There 
are, in addition, trophic changes; the salivary, lachrymal, and buccal secre- 
tions may be lessened, abrasions of the mucous membranes heal slowly, 
and the teeth may become loose. The eye inflames, the corneae become 
cloudy and may ulcerate. It was formerly held that these symptoms only 
occurred when the Gasserian ganglion was affected, but of late years this 
has been completely removed for obstinate neuralgia without producing 
any trophic disturbance. This apparent contradiction is not yet explained. 
Herpes may develop in the region supplied by the nerve, usually the upper 
branch, and is associated with much pain, which may be peculiarly endur- 
ing, lasting for months or years (Gowers). In herpes zoster with the neu- 
ritis there may be slight enlargement of the cervical glands. 

(b) Motor Portion. — The inability to use the muscles of mastication on 
the affected side is the distinguishing feature of paralysis of this portion of 



DISEASES OP THE CEREBRAL NERVES. 



1051 



the nerve. It is recognized by placing the finger on the masseter and tem- 
poral muscles, and, when the patient closes the jaw, the feebleness of their 
contraction is noted. If paralyzed, the external pterygoid cannot move 
the jaw toward the unaffected side; and when depressed, the jaw deviates 
to the paralyzed side. The motor paralysis of the fifth nerve is almost in- 
variably a result of involvement of the nerve after it has left the nucleus. 
Cases, however, have been associated with cortical lesions. Hirt concludes, 
from his case, that the cortical motor centre for the trigeminus is in the 
neighborhood of the lower third of the anterior central convolution. 

Spasm of the Muscles of Mastication. — Trismus, the masticatory spasm 
of Romberg, may be tonic or clonic, and is either an associated phenome- 
non in general convulsions or, more rarely, an independent affection. In 
the tonic form the jaws are kept close together — lock-jaw — or can be sepa- 
rated only for a short space. The muscles of mastication can be seen in 
contraction and felt to be hard; the spasm is often painful. This tonic 
contraction is an early symptom in tetanus, and is sometimes seen in tetany. 
A form of this tonic spasm occurs in hysteria. Occasionally trismus 
follows exposure to cold, and is said to be due to reflex irritation from 
the teeth, the mouth, or caries of the jaw. It may also be a symptom 
of organic disease due to irritation near the motor nucleus of the fifth 
nerve. 

Clonic spasm of the muscles supplied by the fifth occurs in the form of 
rapidly repeated contractions, as in " chattering teeth." This is rare apart 
from general conditions, though cases are on record, usually in women late 
in life, in whom this isolated clonic spasm of the muscles of the jaw has 
been found. In another form of clonic spasm sometimes seen in chorea, 
there are forcible single contractions. Gowers mentions an instance of its 
occurrence as an isolated affection. 

(c) Gustatory. — Loss of the sense of taste in the anterior two thirds of 
the tongue, as a rule, follows paralysis of the fifth nerve. The gustatory 
fibres of the lingual branch of the fifth pass with the ehorda tympani to 
the seventh nerve, which they are believed to leave by the petrosal nerve, 
and to again reach the fifth through Meckel's ganglion. Disease of the 
fifth nerve is, however, not always associated with loss of taste, in which 
case either the taste fibres escape, or the disease is within the pons where 
these fibres are separate from those of sensation. It may be that the 
nervus intermedins of Wrisberg carries the taste fibres. 

The diagnosis of disease of the trifacial nerve is rarely difficult. It 
must be remembered that the preliminary pain and hyperesthesia are 
sometimes mistaken for ordinary neuralgia. The loss of sensation and the 
palsy of the muscles of mastication are readily determined. 

Treatment. — When the pain is severe morphia may be required and 
local applications are useful. If there is a suspicion of syphilis, appropri- 
ate treatment should be given. Faradization is sometimes beneficial. 

Facial ETebve. 

Paralysis (BelVs Palsy). — The facial or seventh may be paralyzed by 
(1) lesions of the cortex — supranuclear palsy; (2) lesions of the nucleus 



1052 



DISEASES OF THE NERVOUS SYSTEM. 



itself; or (3) involvement of the nerve trunk in its tortuous course within 
the pons and through the wall of the skull. 

1. Supranuclear paralysis, due to lesion of the cortex or of the facial 
fibres in the corona radiata or internal capsule, is, as a rule, associated 
with hemiplegia, It may be caused by tumors, abscess, chronic inflamma- 
tion, or softening in the cortex or in the region of the internal capsule. It 
is distinguished from the peripheral form by well-marked characters — the 
persistence of the normal electrical excitability of both nerves and muscles 
and the absence of involvement of the upper branches of the nerve, so that 
the orbicularis palpebrarum, frontalis, and corrugator muscles are spared. 
In some cases the mouth can be pursed by the action of the orbicularis 
oris. In rare instances these muscles are paralyzed. In this form the vol- 
untary movements are more impaired than the emotional. Isolated paral- 
ysis — monoplegia facialis — due to involvement of the cortex or of the 
fibres in their path to the nucleus, is uncommon. In the great majority 
of cases supranuclear facial paralysis is part of a hemiplegia. Paralysis 
is on the same side as that of the arm and leg because the facial muscles 
bear precisely the same relation to the cortex as the spinal muscles. The 
nuclei of origin on either side of the middle line in the medulla are united 
by decussating fibres with the cortical centre on the opposite side (see Fig. 
10). A few fibres reach the nucleus from the cerebral cortex of the same 
side (Melius, Hoche), and this uncrossed path may innervate the upper 
facial muscles (Bruce). 

2. The nuclear paralysis caused by lesions of the nerve centres in the 
medulla is not common alone; but is seen occasionally in tumors, chronic 
softening, and haemorrhage. We have had one instance of its involvement in 
anterior polio-myelitis. In diphtheria this centre may also be involved. 
The symptoms are practically similar to those of an affection of the nerve 
fibre itself — infranuclear paralysis. 

3. Involvement of the Nerve T runic. — Paralysis may result from: 

(a) Involvement of the nerve as it passes through the pons — that is, 
between its nucleus in the floor of the fourth ventricle and the point of 
emergence in the postero-lateral aspect of the pons. The specially inter- 
esting feature in connection with involvement of this part is the production 
of what is called alternating or crossed paralysis, the face being involved on 
the same side as the lesion, and the arm and leg on the opposite side, since 
the motor path is involved above the point of decussation in the medulla 
(Fig. 10). This occurs only when the lesion is in the lower section of the 
pons. A lesion in the upper half of the pons involves the fibres not of the 
outgoing nerve on the same side, but of the fibres from the hemispheres 
before they have crossed to the nucleus of the opposite side. In this case 
there would of course be, as in hemiplegia, paralysis of the face and limbs 
on the side opposite to the lesion. The palsy, too, would resemble the cere- 
bral form, involving only the lower fibres of the facial nerve. 

(b) The nerve may be involved at its point of emergence by tumors, 
gummata, meningitis, or occasionally may be injured in fracture of the 
base. 

(c) In passing through the Fallopian canal the nerve may be involved 
in disease of the ear, particularly by caries of the bone in otitis media. 



DISEASES OF THE CEREBRAL NERVES. 1053 

This is a common cause in children. I have seen two instances follow otitis 
in puerperal fever. 

(d) As the nerve emerges from the styloid foramen it is exposed to 
injuries and blows which not infrequently cause paralysis. The fibres may 
be cut in the removal of tumors in this region, or the paralysis may be 
caused by pressure of the forceps in an instrumental delivery. 

(e) Exposure to cold is the most common cause of facial paralysis, in- 
ducing a neuritis of the nerve within the Fallopian canal. 

(/) Syphilis is not an infrequent cause, and the paralysis may develop 
early with the secondary symptoms. 
(g) It may develop with herpes. 

Facial diplegia is a rare condition occasionally found in affections at 
the base of the brain, lesions in the pons, simultaneous involvement of the 
nerves in ear disease, and in diphtheritic paralysis. Disease of the nuclei 
or symmetrical involvement of the cortex "might also produce it. It may 
occur as a congenital affection. H. M. Thomas has described two cases in 
one family. 

Symptoms.' — In the peripheral facial paralysis all the branches of 
the nerve are involved. The face on the affected side is immobile and can 
neither be moved at will nor participate in any emotional movements. The 
skin is smooth and the wrinkles are effaced, a point particularly notice- 
able on the forehead of elderly persons. The eye cannot be closed, the 
lower lid droops, and the eye waters. On the affected side the angle of 
the mouth is lowered, and in drinking the lips are not kept in close apposi- 
tion to the glass, so that the liquid is apt to run out. In smiling or laugh- 
ing the contrast is most striking, as the affected side does not move, which 
gives a curious unequal appearance to the two sides of the face. The eye 
cannot be closed nor can the forehead be wrinkled. In long-standing 
cases, when the reaction of degeneration is present, if the patient tries to 
close the eyes while looking fixedly at an object the lids on the sound side 
close firmly, but on the paralyzed side there is only a narrowing of the 
palpebral orifice, and the eye is turned upward and outward by the inferior 
oblique. On asking the patient to show his upper teeth, the angle of the 
mouth is not raised. In all these movements the face is drawn to the sound 
side by the action of the muscles. Speaking may be slightly interfered 
with, owing to the imperfection in the formation of the labial sounds. 
"Whistling cannot be performed. In chewing the food, owing to the paraly- 
sis of the buccinator, particles collect on the affected side. The paralysis 
of the nasal muscles is seen on asking the patient to sniff. Owing to the 
fact that the lips are drawn to the sound side, the tongue, when protruded, 
looks as if it were pushed to the paralyzed side; but on taking its position 
from the incisor teeth, it will be found to be in the middle line. The reflex 
movements are lost in this peripheral form. It is usually stated that the 
palate is paralyzed on the same side and that the uvula deviates. Both 
Gowers and Hughlings Jackson deny the existence of this involvement in 
the great majority of cases, and Horsley and Beevor have shown that these 
parts are innervated by the accessory nerve to the vagus. 

When the nerve is involved within the canal between the genu and the 



1054 



DISEASES OF THE NERVOUS SYSTEM. 



origin of the chorda tympani, the sense of taste may be lost in the anterior 
part of the tongue on the affected side, owing probably to injury to the 
nervus intermedins of Wrisberg. When the nerve is damaged outside the 
skull the sense of taste is unaffected. Hearing is often impaired in facial 
paralysis, most commonly by preceding ear-disease. The paralysis of the 
stapedius muscle may lead to increased sensitiveness to musical notes. 
Herpes is sometimes associated with facial paralysis. Pain is not common, 
but there may be neuralgia about the ear. The face on the affected side 
may be swollen. 

The electrical reactions, which are those of a peripheral palsy, have con- 
siderable importance from a prognostic standpoint. ErVs rules are as 
follows: If there is no change, either faradic or galvanic, the prognosis 
is good and recovery takes place in from fourteen to twenty days. If the 
faradic and galvanic excitability of the nerve is only lessened and that of 
the muscle increased to the galvanic current and the contraction formula 
altered (the contraction sluggish AnOCC), the outlook is relatively good 
and recovery will probably take place in from four to six weeks; occasion- 
ally in from eight to ten. When the reaction of degeneration is present — 
that is, if the faradic and galvanic excitability of the nerves and the faradic 
excitability of the muscles are lost and the galvanic excitability of the 
muscle is quantitatively increased and qualitatively changed, and if the 
mechanical excitability is altered — the prognosis is relatively unfavorable 
and the recovery may not occur for two, six, eight, or even fifteen months. 

The course of facial paralysis is usually favorable. The onset in the 
form following cold is very rapid, developing perhaps within twenty-four 
hours, but rarely is the paralysis permanent. Eecurring attacks have been 
described; Sinkler mentions five. On the other hand, in the paralysis from 
injury, as by a blow on the mastoid process, the condition may remain. 
When permanent, the muscles are entirely toneless. In some instances con- 
tracture develops as the voluntary power returns, and the natural folds 
and the wrinkles on the affected side may be deepened, so that on looking 
at the face one at first may have the impression that the affected side is 
the sound one. This is corrected at once on asking the patient to smile, 
when it is seen which side of the face has the most active movement. Are- 
taeus noted the difficulty sometimes experienced in determining which side 
was affected until the patient spoke or laughed. 

The diagnosis of facial paralysis is usually easy. The distinction be- 
tween the peripheral and central form is based on facts already mentioned. 

Treatment. — In the cases which result from cold and are probably 
due to neuritis within the bony canal, hot applications first should be made; 
subsequently the thermo-cautery may be used lightly at intervals of a 
day or two over the mastoid process, or small blisters applied. If the 
ear is diseased, free discharge for the secretion should be obtained. The 
continuous current may be employed to keep up the nutrition of the mus- 
cles. The positive pole should be placed behind the ear, the negative one 
along the zygomatic and other muscles. The application can be made daily 
for a quarter of an hour and the patient can readily b'e taught to make it 
himself before the looking-glass. Massage of the muscles of the face is also 



DISEASES OF THE CEREBRAL NERVES. 



1055 



•useful. A course of iodide of potassium may be given even when there is 
no indication of syphilis. 

In some of the traumatic cases the possibility of surgical interference 
may be considered. In a patient with chronic otitis media of twenty-three 
years' duration and secondary mastoid disease Bloodgood operated in May, 
1896. Complete facial paralysis followed. Eight weeks later the facial 
nerve was exposed in its canal and found to be almost completely severed. 
The ends were brought together and the wound allowed to fill with blood- 
clot, which organized. Four months later the patient had improved, and 
one year and six months from the operation the power had returned to all 
the muscles except the occipito-frontalis and the depressor of the lower lip. 
The response to galvanic and faradic currents was normal. 

Spasm. — The spasm may be limited to a few or involve all the muscles 
innervated by the facial nerve and may be unilateral or bilateral. 

It is known also by the name of mimic spasm or of convulsive tic. Sev- 
eral different affections are usually considered under the name of facial 
or mimic spasm, but we shall here speak only of the simple spasm of the 
facial muscles, either primary or following paralysis, and shall not in- 
clude the cases of habit spasm in children, or the tic convulsif of the 
French. 

Gowers recognizes two classes — one in which there is an organic lesion, 
and an idiopathic form. It is thought to be due also to reflex causes, such 
as the irritation from carious teeth or the presence of intestinal worms. 
The disease usually occurs in adults, whereas the habit spasm and the tic 
convulsif of the French, often confounded with it, are most common in 
children. True mimic spasm occasionally comes on in childhood and per- 
sists. In the case of a school-mate, the affection was marked as early as 
the eleventh or twelfth year and still continues. When the result of or- 
ganic disease, there has usually been a lesion of the centre in the cortex, as 
in the case reported by Berkley, or pressure on the nerve at the base of 
the brain by aneurism or tumor. 

Symptoms. — The spasm may involve only the muscles around the 
eye — blepharospasm — in which case there is constant, rapid, quick action 
of the orbicularis palpebrarum, which, in association with photophobia, 
may be tonic in character. More commonly the spasm affects the lateral 
facial muscles with those of the eye, and there is constant twitching of the 
side of the face with partial closure of the eye. The frontalis is rarely in- 
volved. In aggravated cases the depressors of the angle of the mouth, the 
levator menti, and the platysma myoides are affected. This spasm is con- 
fined to one side of the face in a majority of cases, though it may extend 
and become bilateral. It is increased by emotional causes and by voluntary 
movements of the face. As a rule, it is painless, but there may be tender 
points over the course of the fifth nerve, particularly the supraorbital 
branch. Tonic spasm of the facial muscle may follow paralysis, and is said 
to result occasionally from cold. 

The outlook in facial spasm is always dubious. A majority of the cases 
persist for years and are incurable. 



1056 



DISEASES OF THE NERVOUS SYSTEM. 



Treatment. — Sources of irritation should be looked for and removed. 
When a painful spot is present over the fifth nerve, blistering or the appli- 
cation of the thermo-cautery may relieve it. Hypodermic injections of 
strychnia may be tried, but are of doubtful benefit. Weir Mitchell recom- 
mends the freezing of the cheek for a few minutes daily or every second 
day with the spray, and this, in some instances, is beneficial. Often the re- 
lief is transient; the cases return, and at every clinic may be seen half a 
dozen or more of such patients who have run the gamut of all measures 
without material improvement. Operative interference may be resorted to 
in severe cases, although not much can be expected of it. 

Auditory Nerve. 

The eighth, known also as portio mollis of the seventh pair, passes from 
the ear through the internal auditory meatus, and in reality consists of two 
separate nerves- — the cochlear and vestibular roots. These two roots have 
entirely different functions, and may therefore be best considered separately. 
The cochlear nerve is the one connected with the organ of Corti, and is con- 
cerned in hearing. The vestibular nerve is connected with the vestibule 
and semicircular canals, and has to do with the maintenance of equilibrium. 

The Cochlear Nerve. 

The cortical centre for hearing is in the temporo-sphenoidal lobe. Pri- 
mary disease of the auditory nerve in its centre or intracranial course is 
uncommon. More frequently the terminal branches are affected within the 
labyrinth. 

(a) Affection of the Cortical Centre. — In the monkey, experiments indi- 
cate that the superior temporal gyrus represents the centre for hearing. In 
man the cases of disease indicate that it has the same situation, as destruction 
of this gyrus on the left side results in word-deafness, which may be defined 
as an inability to understand the meaning of words, though they may still 
be heard as sounds. The central auditory path extending to the cortical 
centre from the terminal nuclei of the cochlear nerve may be involved and 
produce deafness. This may result from involvement of the lateral lemnis- 
cus from the presence of a tumor in the corpora quadrigemina, especially 
if it involve the posterior quadrigeminal bodies, from a lesion of the internal 
geniculate body, or it may be associated with a lesion of the internal cap- 
sule. 

(b) Lesions of the nerve at the lase of the brain may result from the 
pressure of tumors, meningitis (particularly the cerebro-spinal form), haem- 
orrhage, or traumatism. A primary degeneration of the nerve may occur 
in locomotor ataxia. Primary disease of the terminal nuclei of the cochlear 
nerve (nucleus nervi cochlearis dorsalis and nucleus nervi cochlearis ven- 
tralis) is rare. By far the most interesting form results from epidemic 
cerebro-spinal meningitis, in which the nerve is frequently involved, caus- 
ing permanent deafness. In young children the condition results in deaf- 
mutism. 



DISEASES OF THE CEREBRAL NERVES. 



1057 



(c) In a majority of the cases associated with auditory-nerve symptoms 
the lesion is in the internal ear, either primary or the result of extension 
of disease of the middle ear. Two groups of symptoms may be produced — 
hyperesthesia and irritation and diminished function or nervous deafness. 

(1) Hyperesthesia and Irritation. — This may be due to altered func- 
tion of the centre as well as of the nerve ending. True hyperesthesia — 
hyperacusis — is a condition in which sounds, sometimes even those inaudi- 
ble to other persons, are heard with great intensity. It occurs in hysteria 
and occasionally in cerebral disease. As already mentioned, in paralysis 
of the stapedius low notes may be heard with intensity. In dysesthesia, 
or dysacusis, ordinary sounds cause an unpleasant sensation, as commonly 
happens in connection with headache, when ordinary noises are badly 
borne. 

Tinnitus aurium is a term employed to designate certain subjective 
sensations of ringing, roaring, ticking, and whirring noises in the ear. It is 
a very common and often a distressing symptom. It is associated with many 
forms of ear-disease and may result from pressure of wax on the drum. It 
is rare in organic disease of the central connections of the nerve. Sudden 
intense stimulation of the nerve may cause it. A form not uncommonly 
met with in medical practice is that in which the patient hears a continual 
'bruit in the ear, and the noise has a systolic intensification, usually on one 
side. I have twice been consulted by physicians for this condition under 
the belief that they had an internal aneurism. A systolic murmur may be 
heard occasionally on auscultation. It occurs in conditions of anemia and 
neurasthenia. Subjective noises in the ear may precede anvepileptic seizure 
and are sometimes present in migraine. In whatever form tinnitus exists, 
though slight and often regarded as trivial, it occasions great annoyance 
and often mental distress, and has even driven patients to suicide. 

The diagnosis is readily made; but it is often extremely difficult to de- 
termine upon what condition the tinnitus depends. The relief of con- 
stitutional states, such as anemia, neurasthenia, or gout, may result in 
cure. A careful local examination of the ear should always be made. One 
of the most worrying forms is the constant clicking, sometimes audible 
many feet away from the patient, and due probably to clonic spasm of the 
muscles connected with the Eustachian tube or of the levator palati. The 
condition may persist for years unchanged, and then disappear suddenly. 
The pulsating forms of tinnitus, in which the sound is like that of a sys- 
tolic bruit, are almost invariably subjective, and it is very rare to hear any- 
thing with the stethoscope. It is to be remembered that in children there 
is a systolic brain murmur, best heard over the ear, and in some instances 
appreciable in the adult. 

(2) Diminished Function or Nervous Deafness. — In testing for nervous 
deafness, if the tuning-fork cannot be heard when placed near the meatus, 
but the vibrations are audible by placing the foot of the tuning-fork against 
the temporal bone, the conclusion may be drawn that the deafness is not 
due to involvement of the nerve. The vibrations are conveyed through 
the temporal bone to the cochlea and vestibule. The watch may be used 
for the same purpose, and if the meatus is closed and the watch is heard 

66 



1058 



DISEASES OF THE NERVOUS SYSTEM. 



better in contact with, the mastoid process than when opposite the open 
meatus, the deafness is probably not nervous. Disturbance of the function 
of the auditory nerve is not a very frequent symptom in brain-disease, but 
in all cases the function of the nerve should be carefully tested. 

The V estibular Nerve. 

The most frequent symptoms met with in association with disease of the 
vestibular nerve and its central connections are vertigo, nystagmus, and 
loss of coordination of the muscles of the head, neck, and eyes. 

Auditory Vertigo — Meniere's Disease. — In 1861 Meniere, a French phy- 
sician, described an affection characterized by noises in the ear, vertigo 
(which might be associated with loss of consciousness), vomiting, and, in 
many cases, progressive loss of hearing. The following grouping of the 
cases has been made by Parkes Weber: (1) The apoplectic form, due to 
haemorrhage into the labyrinth, as in leukaemia, followed, as a rule, by 
complete deafness in one or both ears. (2) The cases associated with pro- 
gressive inflammatory disease of the labyrinth. (3) Associated with organic 
changes in the auditory nerves, as in tumors, sometimes in tabes, and in 
cases of aural vertigo associated with facial paralysis on one side. (4) 
Cases in which a paroxysm of epilepsy is preceded by an auditory aura. 
(5) The moderate attacks which are associated with the various middle- 
ear affections, with wax in the meatus, with violent syringing of the ears, 
etc., all of which are probably due to increase in the intra-labyrinthine 
pressure. Meniere's symptoms may occasionally be due to temporary ex- 
cessive increase in the perilymph, possibly of angioneurotic character. 

Symptoms. — The attack usually sets in suddenly with a buzzing noise 
in the ears and the patient feels as if he was reeling or staggering. He 
may feel himself to be reeling, or the objects about him may seem to be 
turning, or the phenomena may be combined. The attack is often so 
abrupt that the patient falls, though, as a rule, he has time to steady him- 
self by grasping some neighboring object. There may be slight but tran- 
sient loss of consciousness. In a few minutes, or even less, the vertigo 
passes off and the patient becomes pale and nauseated, a clammy sweat 
breaks out on the face, and vomiting may follow. 

The tinnitus is described as either a roaring or a throbbing sound. 
Ocular symptoms may be present; thus, jerking of the eyeballs or nystag- 
mus may develop during the attack, or diplopia. 

Labyrinthine vertigo is paroxysmal, coming on at irregular intervals, 
sometimes of weeks or months; or several attacks may occur in a . day. 

The disturbances of equilibrium, including the vertigo, are dependent 
upon a disturbance of the functions of the vestibular nerve or of the organs 
with which this nerve is connected, either in its peripheral distribution or 
by means of its central connection. The auditory symptoms often accom- 
panying it are doubtless always due to involvement of the cochlear nerve 
or its peripheral or central connections. 

Diagnosis. — The combination of tinnitus with giddiness, with or 
without gastric disturbance, is sufficient to establish a diagnosis. There 
are other forms of vertigo from which it must be distinguished. The form 



DISEASES OF THE CEREBRAL NERVES. 



1059 



known as gastric vertigo, which is associated with dyspepsia and occurs 
most commonly in persons of middle age, is, as a rule, readily distinguished 
by the absence of tinnitus or evidences of disturbance in the function of 
the auditory nerve. This variety of vertigo is much less common than 
Trousseau's description would lead us to believe. It is important to note 
the close connection of vertigo with ocular defects. 

The cardio-vascular vertigo, one of the most common forms, occurs in 
cases of valvular disease, particularly aortic insufficiency, and as frequently 
in arterio-sclerosis. 

Endemic Paralytic Vertigo. — In parts of Switzerland and France there 
is a remarkable form of vertigo described by Gerlier, which is characterized 
by attacks of paretic weakness of the extremities, falling of the eyelids, 
remarkable depression, but with retention of consciousness. It occurs also 
in northern Japan, where Miura says it develops paroxysmally among the 
farm laborers of both sexes and all ages. It is known there as kubisagari. 

Aural vertigo must be carefully distinguished from attacks of petit mal, 
or, indeed, of definite epilepsy. It is rare in petit mal to have noises in the 
ear or actual giddiness, but in the aura preceding an epileptic attack the 
patient may feel giddy. Giddiness and transient loss of consciousness may 
be associated with organic disease of the brain, more particularly with 
tumor. Vomiting also may be present. A careful investigation of the 
symptoms will usually lead to a correct diagnosis. 

The outlook in Meniere's disease is uncertain. While many cases re- 
cover completely, in others deafness results and the attacks recur at shorter 
intervals. In aggravated cases the patient constantly suffers from vertigo 
and may even be confined to his bed. 

Treatment. — Bromide of potassium, in 20-grain doses three times a 
day, is sometimes beneficial. If there is a history of syphilis, the iodide 
should be administered. The salicylates are recommended, and Charcot 
advises quinine to cinchonism. In cases in which there is increase in the 
arterial tension, nitroglycerin may be given, at first in very small doses, but 
increasing gradually. It is not specially valuable in Meniere's disease, but 
in the cases of giddiness in middle-aged men and women associated with 
arterio-sclerosis it sometimes acts very satisfactorily. Correction of errors 
of refraction is sometimes followed by prompt relief of the vertigo. 

Glosso-pharyngeal Nerve (Nervus glossopharyngeus). 

The ninth nerve contains both motor and sensory fibres and is also a 
nerve of the special sense of taste to the tongue. It supplies, by its motor 
branches, the stylo-pharyngeus and the middle constrictor of the pharynx. 
The sensory fibres are distributed to the upper part of the pharynx. 

Symptoms. — Of nuclear disturbance we know very little. The 
pharyngeal symptoms of bulbar paralysis are probably associated with in- 
volvement of the nuclei of this nerve. Lesion of the nerve trunk itself is 
rare, but it may be compressed by in mors or involved in meningitis. Dis- 
turbance of the sense of taste may result from loss of function of this nerve, 
in which case it is chiefly in the posterior part of the tongue and soft pal- 



1060 



DISEASES OF THE NERVOUS SYSTEM. 



ate. Growers, however, states that there is no case on record in which loss 
of taste in these regions has been produced by disease of the roots of the 
glosso-pharyngeal; whereas, on the other hand, disease of the root 
of the fifth nerve may cause loss of taste on the back as well as the front 
of the tongue, as if the taste fibres of the glosso-pharyngeal came from the 
fifth. 

The general disturbances of the sense of taste may here be briefly referred 
to. Loss of the sense of taste — ageusia — may be caused by disturbance of 
the peripheral end organs, as in affections of the mucosa of the tongue. 
This is very common in the dry tongue of fever or the furred tongue of 
dyspepsia, under which circumstances, as the saying is, everything tastes 
alike. Strong irritants too, such as pepper, tobacco, or vinegar, may dull 
or diminish the sense of taste. Complete loss may be due to involvement 
of the nerves either in their course or in the centres. Disturbance in the 
sense of taste is most commonly seen in involvement of the fifth nerve, 
and it may be that this nerve alone subserves the function. Perversion of 
the sense of taste — parageusis — is rarely found, except as an hysterical 
manifestation and in the insane. Increased sensitiveness is still more rare. 
There are occasional subjective sensations of taste, occurring as an aura 
in epilepsy or as part of the hallucinations in the insane. 

To test the sense of taste the patient's eyes should be closed and small 
quantities of various substances applied. The sensation should be per- 
ceived before the tongue is withdrawn. The following are the most suitable 
tests: For bitter, quinine; for sweetness, a strong solution of sugar or sac- 
charin; for acidity, vinegar; and for the saline test, common salt. One 
of the most important tests is the feeble galvanic current, which gives the 
well-known metallic taste. 

Pneumogastric Nerve (Nervus vagus). 

The tenth nerve has an important and extensive distribution, supply- 
ing the pharynx, larynx, lungs, heart, oesophagus, and stomach. The nerve 
may be involved at its nucleus along with the spinal accessory and the hypo- 
glossal, forming what is known as bulbar paralysis. It may be compressed 
by tumors or aneurism, or in the exudation of meningitis, simple or syphi- 
litic. In its course in the neck the trunk may be involved by tumors or 
in wounds. It has been tied in ligature of the carotid, and has been cut 
in the removal of deep-seated tumors. The trunk may be attacked by 
neuritis. 

The affections of the vagus are best considered in connection with the 
distribution of the separate nerves. 

(a) Pharyngeal Branches. — In combination with the glosso-pharyngeal 
the branches from the vagus form the pharyngeal plexus, from which the 
musclee and mucosa of the pharynx are supplied. In paralysis due to 
involvement of this either in the nuclei, as in bulbar paralysis, or in the 
course of the nerve, as in diphtheritic neuritis, there is difficulty in swal- 
lowing and the food is not passed on into the oesophagus. If the nerve on 
one side only is involved, the deglutition is not much impaired. In these 



DISEASES OF THE CEREBRAL NERVES. 1061 

cases the particles of food frequently pass into the larynx, and, when the 
soft palate is involved, into the posterior nares. 

Spasm of the pharynx is always a functional disorder, usually occur- 
ring in hysterical and nervous people. Gowers mentions a case of a gentle- 
man who could not eat unless alone, on account of the inability to swallow 
in the presence of others from spasm of the pharynx. This spasm is a well- 
marked feature in hydrophobia, and I have seen it in a case of pseudo- 
hydrophobia. 

(b) Laryngeal Branches. — The superior laryngeal nerve supplies the 
mucous membrane of the larynx above the cords and the crico-thyroid mus- 
cle. The inferior or recurrent laryngeal curves around the arch of the 
aorta on the left side and the subclavian artery on the right, passes along 
the trachea and supplies the mucosa below the cords and all the muscles of 
the larynx except the crico-thyroid and the epiglottidean. Experiments have 
shown that these motor nerves of the pneumogastric are all derived from 
the spinal accessory. The remarkable course of the recurrent laryngeal 
nerves renders them liable to pressure by tumors within the thorax, par- 
ticularly by aneurism. The following are the most important forms of 
paralysis: 

(1) Bilateral Paralysis of the Abductors. — In this condition, the pos- 
terior crico-arytenoids are involved and the glottis is not opened during 
inspiration. The cords may be close together in the position of phonation, 
and during inspiration may be brought even nearer together by the pressure 
of air, so that there is only a narrow chink through which the air whistles 
with a noisy stridor. This dangerous form of laryngeal paralysis occurs 
occasionally as a result of cold, or may follow a laryngeal catarrh. The 
posterior muscles have been found degenerated when the others were 
healthy. The condition may be produced by pressure upon both vagi, or 
upon both recurrent nerves. As a central affection it occurs in tabes and 
bulbar paralysis, but may be seen also in hysteria. The characteristic symp- 
toms are inspiratory stridor with unimpaired phonation. Possibly, as 
Gowers suggests, many cases of so-called hysterical spasm of the glottis are 
in reality abductor paralysis. 

(2) Unilateral Abductor Paralysis. — This frequently results from the 
pressure of tumors or involvement of one recurrent nerve. Aneurism is 
by far the most common cause, though on the right side the nerve may be 
involved in thickening of the pleura. " The symptoms are hoarseness or 
roughness of the voice, such as is so common in aneurism. Dyspnoea is not 
often present. The cord on the affected side does not move in inspiration. 
Subsequently the adductors may also become involved, in which case the 
phonation is still more impaired. 

(3) Adductor Paralysis. — This results from involvement of the lateral 
crico-arytenoid and the arytenoid muscle itself. It is common in hysteria, 
particularly of women, and causes the hysterical aphonia, which may come 
on suddenly. It may result from catarrh of the larynx or from overuse of 
the voice. In laryngoscopic examination it is seen, on attempt at phonation, 
that there is no power to bring the cords together. In this connection the 
following table from Gowers' work will be found valuable to the student: 



1062 



DISEASES OF THE NERVOUS SYSTEM. 



Symptoms. 

No voice ; no cough ; 
stridor only on deep in- 
spiration. 

Voice low pitched 
and hoarse ; no cough ; 
stridor absent or slight 
on deep breathing. 



Voice little changed ; 
cough normal ; inspira- 
tion difficult and long, 
with loud stridor. 

Symptoms incon- 
clusive; little affection 
of voice or cough. 

No voice ; perfect 
cough; no stridor or 
dyspnoea. 



Signs. 

Both cords moder- 
ately abducted and mo- 
tionless. 

One cord moder- 
ately abducted and mo- 
tionless, the other mov- 
ing freely, and even 
beyond the middle line 
in phonation. 

Both cords near to- 
gether, and during in- 
spiration not separated, 
but even drawn nearer 
together. 

One cord near the 
middle line not moving 
during inspiration, the 
other normal. 

Cords normal in po- 
sition and moving nor- 
mally in respiration, 
but not brought to- 
gether on an attempt 
at phonation. 



Lesion. 
Total bilateral palsy. 

Total unilateral palsy. 



Total abductor palsy. 



Unilateral abductor 



Adductor palsy. 



Spasm of the Muscles of the Larynx. — In this the adductor muscles are 
involved. It is not an uncommon affection in children, and has already 
been referred to as laryngismus stridulus. Paroxysmal attacks of laryngeal 
spasm are rare in the adult, but cases are described in which the patient, 
usually a young girl, wakes at night in an attack of intense dyspnoea, which 
may persist long enough to produce cyanosis. Liveing states that they may 
replace attacks of migraine. They occur in a characteristic form in loco- 
motor ataxia, forming the so-called laryngeal crises. There is a condition 
known as spastic aphonia, in which, when the patient attempts to speak, 
phonation is completely prevented by a spasm. 

Disturbance of the sensory nerves of the larynx is rare. 

Anaesthesia may occur in bulbar paralysis and in diphtheritic neuritis — 
a serious condition, as portions of food may enter the windpipe. It is 
usually associated with dysphagia and is sometimes present in hysteria. 
Hyperesthesia of the larynx is rare. 

(c) Cardiac Branches. — The cardiac plexus is formed by the union of 
branches of the vagi and of the sympathetic nerves. The vagus fibres sub- 
serve motor, sensory, and probably trophic functions. 

(1) Motor. — The fibres which inhibit, control, and regulate the cardiac 
action pass in the vagi. Irritation may produce slowing of the action. Czer- 
mak could slow or even arrest the heart's action for a few beats by pressing 
a small tumor in his neck against one pneumogastric nerve, and it is said 



DISEASES OF THE CEREBRAL NERVES. 



1063 



that the same can be produced by forcible bilateral pressure on the carotid 
canal. There are instances in which persons appear to have had volun- 
tary control over the action of the heart. Cheyne mentions the case of 
Colonel Townshend, " who could die or expire when he pleased, and yet 
by an effort or somehow come to life again, which it seems he had some- 
times tried before he had sent for us." Retardation of the heart's action 
has also followed accidental ligature of one vagus. Irritation at the nuclei 
may also be accompanied with a neurosis of this nerve. On the other hand, 
when there is complete paralysis of the vagi, the inhibitory action may be 
abolished and the acceleratory influences have full sway. The heart's 
action is then greatly increased. This is seen in some instances of diph- 
theritic neuritis and in involvement of the nerve by tumors, or its accidental 
removal or ligature. Complete loss of function of one vagus may, however, 
not be followed by any symptoms. 

(2) Sensory symptoms on the part of the cardiac branches are very 
varied. Normally, the heart's action proceeds regularly without the par- 
ticipation of consciousness, but the unpleasant feelings and sensations of 
palpitation and pain are conveyed to the brain through this nerve. How 
far the fibres of the pneumogastric are involved in angina it is impossible 
to say. The various disturbances of sensation are described under the car- 
diac neuroses. 

(d) Pulmonary Branches. — We know very little of the pulmonary 
branches of the vagi. The motor fibres are stated to control the action of 
the bronchial muscles, and it has long been held that asthma may be a neu- 
rosis of these fibres. The various alterations in the respiratory rhythm are 
probably due more to changes in the centre than in the nerves themselves. 

(e) Gastric and (Esophageal Branches. — The muscular movements of 
these parts are presided over by the vagi and vomiting is induced through 
them, usually reflexly, but also by direct irritation, as in meningitis. Spasm 
of the oesophagus generally occurs with other nervous phenomena. Gas- 
tralgia may sometimes be due to cramp of the stomach, but is more com- 
monly a sensory disturbance of this nerve, due to direct irritation of the 
peripheral ends, or is a neuralgia of the terminal fibres. Hunger is said 
to be a sensation aroused by the pneumogastric, and some forms of nervous 
dyspepsia probably depend upon disturbed function of this nerve. The 
severe gastric crises which occur in locomotor ataxia are due to central 
irritation of the nuclei. Some describe exophthalmic goitre under lesions 
of the vagi. 

Spinal Accessory Nerve (Nervus accessor ius). 

Paralysis. — The smaller or internal part of this nerve joins the vagus 
and is distributed through it to the laryngeal muscles. The larger external 
part is distributed to the sterno-mastoid and trapezius muscles. 

The nuclei of the nerve, particularly of the accessory part, may be in- 
volved in bulbar paralysis. The nuclei of the external portion, situated 
as they are in the cervical cord, may be attacked in progressive degenera- 
tion of the motor nuclei of the cord. The nerve may be involved in the 
exudation of meningitis, or be compressed by tumors, or in caries. The 



1064 



DISEASES OF THE NERVOUS SYSTEM. 



symptoms of paralysis of the accessory portion which joins the vagus have 
already been given in the account of the palsy of the laryngeal branches 
of the pneumogastric. Disease or compression of the external portion is 
followed by paralysis of the sterno-mastoid and of the trapezius on the 
same side. In paralysis of one sterno-mastoid, the patient rotates the head 
with difficulty to the opposite side, but there is no torticollis, though in 
some cases the head is held obliquely. As tire trapezius is supplied in part 
from the cervical nerves, it is not completely paralyzed, but the portion 
which passes from the occipital bone to the acromion is functionless. The 
paralysis of the muscle is well seen when the patient draws a deep breath 
or shrugs the shoulders. The middle portion of the trapezius is also weak- 
ened, the shoulder droops a little, and the angle of the scapula is rotated 
inward by the action of the rhomboids and the levator anguli scapulae. 
Elevation of the arm is impaired, for the trapezius does not fix the scapula 
as a point from which the deltoid can work. 

In progressive muscular atrophy we sometimes see bilateral paralysis 
of these muscles. Thus, if the sterno-mastoids are affected, the head tends 
to fall back; when the trapezii are involved, it falls forward, a characteristic 
attitude of the head in many cases of progressive muscular atrophy. Glowers 
suggests that lesions of the accessory in difficult labor may account for those 
cases in which during the first year of life the child has great difficulty in 
holding up the head. In children this drooping of the head is an impor- 
tant symptom in cervical meningitis, the result of caries. 

The treatment of the condition depends much upon the cause. In the 
central nuclear atrophy but little can be done. In paralysis from pressure 
the symptoms may gradually be relieved. The paralyzed muscles should 
be stimulated by electricity and massage. 

Accessory Spasm.— (Torticollis; Wryneck.) — The forms of spasm af- 
fecting the cervical muscles are best considered here, as the muscles sup- 
plied by the accessory are chiefly, though not solely, responsible for the 
condition. The following forms may be described in this section: 

(a) Congenital Torticollis. — This condition, also known as fixed torti- 
collis, depends upon the shortening and atrophy of the sterno-mastoid on 
one side. It occurs in children and may not be noticed for several years 
on account of the shortness of the neck, the parents often alleging that it 
has only recently come on. It affects the right side almost exclusively. A 
remarkable circumstance in connection with it is the existence of facial 
asymmetry noted by Wilks, which appears to be an essential part of this 
congenital form. It occurred in 6 cases reported by Golding-Bird. In 
congenital wryneck the sterno-mastoid is shortened, hard and firm, and in 
a condition of more or less advanced atrophy. This must be distinguished 
from the local thickening in the sterno-mastoid due to rupture, which may 
occur at the time of birth and produce an induration or muscle callus. 
Although the sterno-mastoid is almost always affected, there are rare cases 
in which the fibrous atrophy affects the trapezius. This form of wryneck 
in itself is unimportant, since it is readily relieved by tenotomy, but 
Golding-Bird states that the facial asymmetry persists, or indeed may, as 
shown by photographs in my case, become more evident. With reference 



DISEASES OF THE CEREBRAL NERVES. 



1065 



to the pathology of the affection, Golding-Bird concludes that the facial 
asymmetry and the torticollis are integral parts of one affection which has 
a central origin and is the counterpart in the head and neck of infantile 
paralysis with talipes in the foot. 

(b) Spasmodic Wryneck. — Two varieties of this spasm occur, the tonic 
and the clonic, which may alternate in the same case; or, as is most com- 
mon, they are separate and remain so from the outset. The disease is 
most frequent in adults and, according to Gowers, more common in females. 
In this country it is certainly more frequent in males. Of the 8 or 10 cases 
which came under my observation in Montreal and Philadelphia, all were 
males. In females it may be an hysterical manifestation. There may be 
a marked neurotic family history, but it is usually impossible to fix upon 
any definite etiological factor. Some cases have followed cold; others 
a blow. 

The symptoms are well defined. In the tonic form the contracted 
sterno-mastoid draws the occiput toward the shoulder of the affected side; 
the chin is raised, and the face rotated to the other shoulder. The sterno- 
mastoid may be affected alone or in association with the trapezius. When 
the latter is implicated the head is depressed still more toward the same 
side. In long-standing cases these muscles are prominent and very rigid. 
There may be some curvature of the spine, the convexity of which is toward 
the sound side. The cases in which the spasm is clonic are much more 
distressing and serious. The spasm is rarely limited to a single muscle. 
The sterno-mastoid is almost always involved and rotates the head so as to 
approximate the mastoid process to the inner end of the clavicle, turning 
the face to the opposite side and raising the chin. When with this the 
trapezius is affected, the depression of the head toward the same side is 
more marked. The head is drawn somewhat backward; the shoulder, too, 
is raised by its action. According to Gowers, the splenius is associated 
with the sterno-mastoid about half as frequently as the trapezius. Its action 
is to incline the head and rotate it slightly toward the same side. Other 
muscles may be involved, such as the scalenus and platysma myoides; and 
in rare cases the head may be rotated by the deep cervical muscles, the 
rectus and obliquus. There are cases in which the spasm is bilateral, caus- 
ing a backward movement — the retro-collic spasm. This may be either 
tonic or clonic, and in extreme cases the face is horizontal and looks upward. 

These clonic contractions may come on without warning, or be pre- 
ceded for a time by irregular pains or stiffness of the neck. The jerking 
movements recur every few moments, and it is impossible to keep the head 
still for more than a minute or two. In time the muscles undergo hyper- 
trophy and may be distinctly larger on one side than the other. In some 
cases the pain is considerable; in others there is simply a feeling of fatigue. 
The spasms cease during sleep. Emotion, excitement, and fatigue increase 
them. The spasm may extend from the muscles of the neck and involve 
those of the face or of the arms. 

The disease varies much in its course. Cases occasionally get well, but 
the great majority of them persist, and, even if temporarily relieved, the 
disease frequently recurs. The affection is usually regarded as a functional 



1066 



DISEASES OF THE NERVOUS SYSTEM. 



neurosis, but it is possibly due to disturbance of the cortical centres presid- 
ing over the muscles. 

Treatment. — Temporary relief is sometimes obtained; a permanent 
cure is exceptional. Various drugs have been used, but rarely with benefit. 
Occasionally, large doses of bromide will lessen the intensity of the spasm. 
Morphia, subcutaneously, has been successful in some reported cases, but 
there is the great danger of establishing the morphia habit. Galvanism 
may be tried. Counter-irritation is probably useless. Fixation of the head 
mechanically can rarely be borne by the patient. These obstinate cases fall 
ultimately into the hands of the surgeon, and the operations of stretching, 
division, and excision of the accessory nerve and division of the muscles 
have been tried. The last does not check the spasm, and may aggravate 
the symptoms. Temporary relief may follow, but, as a rule, the condition 
returns. Eisien Eussell thinks that resection of the posterior branches of 
the upper cervical nerves is most likely to give relief, and this has been 
done by Keen and others. 

(c) The nodding spasm of children may here be mentioned as involving 
chiefly the muscles innervated by the accessory nerve. It may be a simple 
trick, a form of habit spasm, or a phenomenon of epilepsy (E. nutans), in 
which case it is associated with transient loss of consciousness. A similar 
nodding spasm may occur in older children. In women it sometimes occurs 
as an hysterical manifestation, commonly as part of the so-called salaam 
convulsion. 

Hypoglossal Nekve. 

This is the motor nerve of the tongue and for most of the muscles at- 
tached to the hyoid bone. Its cortical centre is probably the lower part of 
the anterior central gyrus. 

Paralysis. — (1) Cortical Lesion. — The tongue is often involved in hemi- 
plegia, and the paralysis may result from a lesion of the cortex itself, or of 
the fibres as they pass to the medulla. It does not occur alone and is 
considered with hemiplegia. There is this difference, however, between 
the cortical and other forms, that the muscles on both sides of the tongue 
may be more or less affected but do not waste, nor are their electrical re- 
actions disturbed. 

(2) Nuclear and infra-nuclear lesions of the hypoglossal result from 
slow progressive degeneration, as in bulbar paralysis or in locomotor ataxia; 
occasionally there is acute softening from obstruction of the vessels. 
The nuclei of both nerves are usually affected together, but may be attacked 
separately. Trauma and lead poisoning have also been assigned as causes. 
The fibres may be damaged by a tumor, and at the base by meningitis; 
or the nerve is sometimes involved in the condylar foramen by disease of the 
skull. It may be involved in its course in a scar, as in Birkett's case, or 
compressed by a tumor in the parotid region, as in a case at present under 
my care. As a result, there is loss of function in the nerve fibres and the 
tongue undergoes atrophy on the affected side. It is protruded toward the 
paralyzed side and may show fibrillary twitching. 

The symptoms of involvement of one hypoglossal, either at its centre 



DISEASES OF THE SPINAL NERVES. 



1067 



or in its course, are those of unilateral paralysis and atrophy of the tongue. 
When protruded, it is pushed toward the affected side, and there are fibril- 
lary twitchings. The atrophy is usually marked and the mucous membrane 
on the affected side is thrown into folds. Articulation is not much im- 
paired in the unilateral affection. There is a remarkable triad of symptoms, 
to which Hughlings Jackson first called attention — unilateral hemi-atrophy 
of the tongue, loss of power in the palate muscle, with paralysis of the 
larynx on the same side. When the disease is bilateral, the tongue lies 
almost motionless in the floor of the mouth; it is atrophied, and can- 
not be protruded. Speech and mastication are extremely difficult and 
deglutition may be impaired. If the seat of the disease is above the 
nuclei, there may be little or no wasting. The condition is seen in 
progressive bulbar paralysis and occasionally in progressive muscular 
atrophy. 

The diagnosis is readily made and the situation of the lesion can usu- 
ally be determined, since when supra-nuclear there is associated hemi- 
plegia and no wasting of the muscles of the tongue. Nuclear disease is 
only occasionally unilateral; most commonly bilateral and part of a bulbar 
paralysis. It should be borne in mind that the fibres of the hypoglossal 
may be involved within the medulla after leaving their nuclei. In such 
a case there may be paralysis of the tongue on one side and paralysis of 
the limbs on the opposite side, and the tongue, when protruded, is pushed 
toward the sound side. 

Spasm. — This rare affection may be unilateral or bilateral. It is most 
frequently a part of some other convulsive disorder, such as epilepsy, 
chorea, or spasm of the facial muscles. In some cases of stuttering, spasm 
of the tongue precedes the explosive utterance of the words. It may occur 
in hysteria, and is said to follow reflex irritation in the fifth nerve. The 
most remarkable cases are those of paroxysmal clonic spasm, in which the 
tongue is rapidly thrust in and out, as many as forty or fifty times a minute. 
In the case reported by Gowers the attacks occurred during sleep and con- 
tinued for a year and a half. The spasm is usually bilateral. Wendt has 
reported a case in which it was unilateral. The prognosis is usually good. 

IV. DISEASES OF THE SPINAL NERVES. 

Cervical Plexus. 

(1) Occipito-cervical Neuralgia. — This involves the nerve territory sup- 
plied by the second, the occipitalis major and minor, and the auricularis 
magnus nerves. The pains are chiefly in the back of the head and neck 
and in the ear. The condition may follow cold and is sometimes associated 
with stiffness of the neck or torticollis. Unless connected with it there 
exists disease of the bones or due to pressure of tumors, the outlook is usu- 
ally good. There are tender points midway between the mastoid process 
and the spine and just above the parietal eminence, and between the sterno- 
mastoid and the trapezius. The affection may be due to direct pressure, in 
persons who carry very heavy loads on the neck. 



1068 



DISEASES OF THE NERVOUS SYSTEM. 



(2) Affections of the Phrenic Nerve. — Paralysis may follow a lesion in 
the anterior horns at the level of the third and fourth cervical nerves, or 
may be dne to compression of the nerve by tumors or aneurism. More 
rarely paralysis results from neuritis. 

It may be part of a diphtheritic or lead palsy and is usually bilateral. 
When the diaphragm is paralyzed respiration is carried on by the inter- 
costal and accessory muscles. When the patient is quiet and at rest little 
may be noticed, but the abdomen retracts in inspiration and is forced out 
in expiration. On exertion or even on attempting to move there may be 
dyspnoea. If the paralysis sets in suddenly there may be dyspnoea and 
lividity, which is usually temporary (W. Pasteur). Intercurrent attacks of 
bronchitis seriously aggravate the condition. Difficulty in coughing, owing 
to the impossibility of drawing a full breath, adds greatly to the danger 
of this complication, as the mucus accumulates in the tubes. 

When the phrenic nerve is paralyzed on one side the paralysis may be 
scarcely noticeable, but careful inspection shows that the descent of the 
diaphragm is much less on the affected side. 

The diagnosis of paralysis is not always easy, particularly in women, 
who habitually use this muscle less than men, and in whom the diaphrag- 
matic breathing is less conspicuous. Immobility of the diaphragm is not 
uncommon, particularly in diaphragmatic pleurisy, in large effusions, and 
in extensive emphysema. The muscle itself may be degenerated and its 
power impaired. 

Owing to the lessened action of the diaphragm, there is a tendency to 
accumulation of blood at the bases of the lungs, and there may be im- 
paired resonance and signs of oedema. As a rule, however, the paralysis is 
not confined to this muscle, but is part of a general neuritis or an anterior 
polio-myelitis, and there are other symptoms of value in determining its 
presence. The outlook is usually serious. Pasteur states that of 15 cases 
following diphtheria, only 8 recovered. The treatment is that of the neuri- 
tis or polio-myelitis with which it is associated. 

Hiccough. — Here may, perhaps, best be considered this remarkable symp- 
tom, caused by intermittent, sudden contraction of the diaphragm. The 
mechanism, however, is complex, and while the afferent impressions to the 
respiratory centre may be peripheral or central, the efferent are distributed 
through the phrenic nerve to the diaphragm, causing the intermittent 
spasm, and through the laryngeal branches of the vagus to the glottis, caus- 
ing sudden closure as the air is rapidly inspired. 

Obstinate hiccough is one of the most distressing of all symptoms, and 
may tax to the uttermost the resources of the physician. W. Langford 
Symes in a recent study groups the cases into: 

(a) Inflammatory, seen particularly in affections of the abdominal vis- 
cera, gastritis, peritonitis, hernia, internal strangulation, appendicitis, sup- 
purative pancreatitis, and in the severe forms of typhoid fever. 

(b) Irritative, as in the direct stimulus of the diaphragm in the swal- 
lowing of very hot substances, local disease of the oesophagus near the 
diaphragm, and in many conditions of gastric and intestinal disorder, more 
particularly those associated with flatus. 



DISEASES OF THE SPINAL NERVES. 



1069 



(c) Specific, or, perhaps more properly, idiopathic, in which no evident 
causes are present. In these cases there is usually some constitutional taint, 
as gout, diabetes, or chronic Bright's disease. I have seen several instances 
of obstinate hiccoughan the later stages of chronic interstitial nephritis. 

(d) Neurotic, cases in which the primary cause is in the nervous system; 
hysteria, epilepsy, shock, or cerebral tumors. Of these cases the hysterical 
are, perhaps, the most obstinate. 

The treatment is often very unsatisfactory. Sometimes in the milder 
forms a sudden reflex irritation will check it at once. Eeaders of Plato's 
Symposium will remember that the physician Eryximachus recommended 
to Aristophanes, who had hiccough from eating too much, either to hold 
his breath (which for trivial forms of hiccough is very satisfactory) or to 
gargle with a little water; but if it still continued, " tickle your nose with 
something and sneeze; and if you sneeze once or twice even the most vio- 
lent hiccough is sure to go." The attack must have been of some severity, 
as it is stated subsequently that the hiccough did not disappear until Aris- 
tophanes had resorted to the sneezing. 

Ice, a teaspoonful of salt and lemon- juice, or salt and vinegar, or a tea- 
spoonful of raw spirits may be tried. When the hiccough is due to gas- 
tric irritation, lavage is sometimes promptly curative. I saw a case 
of a week's duration cured by a hypodermic injection of gr. -J of apomor- 
phia. In obstinate cases the various antispasmodics have been used in suc- 
cession. Pilocarpine has been recommended. The ether spray on the epi- 
gastrium may be promptly curative. Hypodermics of morphia, inhalations 
of chloroform, the use of nitrite of amyl and of nitroglycerin, have been 
beneficial in some cases. Galvanism over the phrenic nerve, or pressure 
on the nerves, applied between the heads of the sterno-cleido-mastoid mus- 
cles may be used. Strong retraction of the tongue may give immediate 
relief. 

Bkachial Plexus. 

(1) Combined Paralysis. — The plexus may be involved in the supra- 
clavicular region by compression of the nerve trunks as they leave the spine, 
or by tumors and other morbid processes in the neck. Below the clavicle 
lesions are more common and result from injuries following dislocation 
or fracture, sometimes from neuritis. The most common cause of lesion of 
the brachial plexus is luxation of the humerus, particularly the subcoracoid 
form. If the dislocation is quickly reduced the symptoms are quite tran- 
sient, and disappear in a few days. In severe cases all the branches of the 
plexus, or only one or two, may be involved. The most serious cases are 
those in which the dislocation is undetected or unreduced for some time, 
when the prolonged pressure on the nerves may cause complete and perma- 
nent paralysis of the arm. The muscles waste, the reaction of degeneration 
is present, and trophic changes in the skin are apt to occur. The medico- 
legal bearings of these cases are important, and may be thus briefly sum- 
marized: Direct injury, as by a fall or blow on the shoulder, resulting in 
great bruising of the nerves without dislocation, is occasionally followed by 
complete paralysis of the arm. A dislocation may be set immediately and 



DISEASES OF THE NERVOUS SYSTEM. 



yet the lesion of the brachial plexus may be such as to cause permanent 
paralysis of the nerves. The dislocation may be reduced and the joint in 
subsequent movements slips out again. It has happened that by the time 
the surgeon sees the patient again, the damage has become irreparable. 

Injuries and blows on the neck may cause partial paralysis of the arm, 
involving the deltoid, supraspinatus, infraspinatus, biceps, brachialis an- 
ticus, and the supinator. The injury may occur to the child during de- 
livery. 

A primary neuritis of the brachial plexus is rare. More commonly the 
process is an ascending neuritis from a lesion of a peripheral branch, involv- 
ing first the radial or ulnar nerves, and spreading upward to the plexus, 
producing gradually complete loss of power in the arm. 

(2) Lesions of Individual Nerves of the Plexus. — (a) Long Thoracic 
Nerve (Serratus Palsy). — This occurs chiefly in men. The nerve is- injured 
in the posterior triangle of the neck, usually by direct pressure in the carry- 
ing of loads; cold may cause neuritis. It may be involved also in pro- 
gressive muscular atrophy and in polio-myelitis anterior. When paralyzed 
the scapula on the affected side looks winged, which results from the pro- 
jection of the angle and posterior border. This is particularly noticeable 
when the arm is moved forward, when the serratus no longer holds the 
scapula against the thorax. It is a well-defined and readily recognized 
form of paralysis. The onset is associated with, sometimes preceded by, 
neuralgic pains. The course is dubious, and many months may elapse 
before there is any improvement. 

(b) Circumflex Nerve.-. — This supplies the deltoid and the teres minor. 
The nerve is apt to be involved in injuries, in dislocations, bruising by a 
crutch, or sometimes by extension of inflammation from the joint. Occa- 
sionally the paralysis arises from a pressure neuritis during an illness. As 
a consequence of loss of power in the deltoid, the arm cannot be raised. 
The wasting is usually marked and changes the shape of the shoulder. 
Sensation may also be impaired in the skin over the muscle. The joint 
may be relaxed and there may be a distinct space between the head of the 
humerus and the acromion. In other instances the ligaments are thick- 
ened, and a condition not unlike ankylosis may be produced, but which is 
readily distinguished on moving the arm. 

(c) Musculo-spiral Paralysis; Radial Paralysis. — This is one of the 
most common of peripheral palsies, and results from the exposed position 
of the musculo-spiral nerve. It is often bruised in the use of the crutch, 
by injuries of the arm, blows, or fractures. It is frequently injured when 
a person falls asleep with the arm over the back of a chair, or by pressure 
of the body upon the arm when a person is sleeping on a bench or on the 
ground. It may be paralyzed by sudden violent contraction of the triceps. 
It is sometimes involved in a neuritis from cold, but this is uncommon in 
comparison with other causes. In the subcutaneous injection of ether the 
nerve may be accidentally struck and temporarily paralyzed. The paraly- 
sis of lead poisoning is the result of involvement of certain branches of 
this nerve. 

A lesion when high up involves the triceps, the brachialis anticus, and 



DISEASES OF THE SPINAL NERVES. 



1071 



the supinator longus, as well as the extensors of the wrist and fingers. 
Naturally, in lesions just above the elbow the arm muscles and the supinator 
longus are spared. The most characteristic feature of the paralysis is the 
wrist-drop and the inability to extend the first phalanges of the fingers and 
thumb. In the pressure palsies the supinators are usually involved and 
the movements of supination cannot be accomplished. The sensations may 
be impaired, or there may be marked tingling, but the loss of sensation is 
rarely so pronounced as that of motion. 

The affection is readily recognized, but it is sometimes difficult to say 
upon what it depends. The sleep and pressure palsies are, as a rule, uni- 
lateral and involve the supinator longus. The paralysis from lead is bi- 
lateral and the supinators are unaffected. Bilateral wrist-drop is a very 
common symptom in many forms of multiple neuritis, particularly the 
alcoholic; but the mode of onset and the involvement of the legs and arms 
are features which make the diagnosis easy. The duration and course 
of the musculo-spiral paralyses are very variable. The pressure palsies may 
disappear in a few days. Eecovery is the rule, even when the affection lasts 
for many weeks. The electrical examination is of importance in the prog- 
nosis, and the rules laid down under paralysis of the facial nerve hold good 
here. 

The treatment is that of neuritis. 

(d) Ulnar Nerve. — The motor branches supply the ulnar halves of the 
deep flexor of the fingers, the muscles of the little finger, the interossei, 
the adductor and the inner head of the short flexor of the thumb, and the 
ulnar flexor of the wrist. The sensory branches supply the ulnar side of 
the hand — two and a half fingers on the back, and one and a half fingers 
on the front. Paralysis may result from pressure, usually at the elbow- 
joint, although the nerve is here protected. Possibly the neuritis in the 
ulnar nerve in some cases of acute illness may be due to this cause. Gowers 
mentions the case of a lady who twice had ulnar neuritis after confinement. 
Owing to paralysis of the ulnar flexor of the wrist, the hand moves toward 
the radial side; adduction of the thumb is impossible; the first phalanges 
cannot be flexed, and the others cannot be extended. In long-standing 
cases the first phalanges are overextended and the others strongly flexed, 
producing the claw-hand; but this is not so marked as in the progressive 
muscular atrophy. The loss of sensation corresponds to the sensory dis- 
tribution just mentioned. 

(e) Median Nerve. — This supplies the flexors of the fingers except the 
ulnar half of the deep flexors, the abductor and the flexors of the thumb, 
the two radial lumbricales, the pronators, and the radial flexor of the wrist. 
The sensory fibres supply the radial side of the palm and the front of t ho 
thumb, the first two fingers and half the third finger, and the dorsal sur- 
faces of the same three fingers. 

This nerve is seldom involved alone. Paralysis results from injury and 
occasionally from neuritis. The signs are inability to pronate the forearm 
beyond the mid-position. The wrist can only be Hexed toward the ulnar 
side; the thumb cannot be opposed to the tips of fingers. The second 
phalanges cannot be flexed on the first; the distal phalanges of the first 



1072 



DISEASES OF THE NEEVOUS SYSTEM. 



and second fingers cannot be flexed; but in the third and fourth fingers 
this action can be performed by the ulnar half of the flexor profundus. The 
loss of sensation is in the region corresponding to the sensory distribution 
already mentioned. The wasting of the thumb muscles, which is usually 
marked in this paralysis, gives to it a characteristic appearance. 

LUMBAR AND SACRAL PLEXUSES. 

The lumbar plexus is sometimes involved in growths of the lymph- 
glands, in psoas abscess, and in disease of the bones of the vertebras. Of 
its branches the obturator nerve is occasionally injured during parturition. 
When paralyzed the power is lost over the adductors of the thigh and one 
leg cannot be crossed over the other. Outward rotation is also disturbed. 
The anterior crural nerve is sometimes involved in wounds or in disloca- 
tion of the hip- joint, less commonly during parturition, and sometimes 
by disease of the bones and in psoas abscess. The special symptoms of affec- 
tion of this nerve are paralysis of the extensors of the knee with wasting 
of the muscles, anaesthesia of the antero-lateral parts of the thigh arid of the 
inner side of the leg to the big toe. This nerve is sometimes involved early 
in growths about the spine, and there may be pain in its area of distribu- 
tion. Loss of the power of abducting the thigh results from paralysis of 
the gluteal nerve, which is distributed to the gluteus, medius, and minimus 
muscles. 

The sacral plexus is frequently involved in tumors and inflammations 
within the pelvis and may be injured during parturition. Neuritis is com- 
mon, usually an extension from the sciatic nerve. 

Of the branches, the sciatic nerve, when injured at or near the notch, 
causes paralysis of the flexors of the legs and the muscles below the knee, 
but injury below the middle of the thigh involves only the latter muscles. 
There is also anaesthesia of the outer half of the leg, the sole, and the greater 
portion of the dorsum of the foot. Wasting of the muscles frequently fol- 
lows, arid there may be trophic disturbances. In paralysis of one sciatic 
the leg is fixed at the knee by the action of the quadriceps extensor and the 
patient is able to walk. 

Paralysis of the small sciatic nerve is rarely seen. The gluteus maximus 
is involved and there may be difficulty in rising from a seat. There is a 
strip of anaesthesia along the back of the middle third of the thigh. 

External Popliteal Nerve. — Paralysis involves the peronaei, the long ex- 
tensor of the toes, tibialis anticus, and the extensor brevis digitomm. The 
ankle cannot be flexed, resulting in a condition known as foot-drop, and 
as the toes cannot be raised the whole leg must' be lifted, producing the 
characteristic steppage gait seen in so many forms of peripheral neuritis. 
In long-standing cases the foot is permanently extended and there is wasting 
of the anterior tibial and peroneal muscles. The loss of sensation is in the 
outer half of the front of the leg and on the dorsum of the foot, 

Internal Popliteal Nerve. — When paralyzed, plantar flexion of the foot 
and flexion of the toes are impossible. The foot cannot be adducted, nor 
can the patient rise on tiptoe. In long-standing cases talipes calcaneus 



DISEASES OF THE SPINAL NERVES. 



1073 



follows and the toes assume a claw-like position from secondary contracture, 
due to overextension of the proximal and flexion of the second and third 
phalanges. 

Sciatica. 

This is, as a rule, a neuritis either of the sciatic nerve or of its cords 
of origin. It may in some instances be a functional neurosis or neuralgia. 

It occurs most commonly in adult males. A history of rheumatism or 
of gout is present in many cases. Exposure to cold, particularly after 
heavy muscular exertion, or a severe wetting are not uncommon causes. 
Within the pelvis the nerves may be compressed by large ovarian or uterine 
tumors, by lymphadenomata, by the fcetal head during labor; occasion- 
ally lesions of the hip-joint induce a secondary sciatica. The condition 
of the nerve has been examined in a few cases, and it has often been seen 
in the operation of stretching. It is, as a rule, swollen, reddened, and in a 
condition of interstitial neuritis. The affection may be most intense at the 
sciatic notch or in the nerve about the middle of the thigh. 

Of the symptoms, pain is the most constant and troublesome. The 
onset may be severe, with slight pyrexia, but, as a rule, it is gradual, and 
for a time there is only slight pain in the back of the thigh, particularly 
in certain positions or after exertion. Soon the pain becomes more intense, 
and instead of being limited to the upper portion of the nerve, extends 
down the thigh, reaching the foot and radiating over the entire distribu- 
tion of the nerve. The patient can often point out the most sensitive spots, 
usually at the notch or in the middle of the thigh; and on pressure these 
are exquisitely painful. The pain is described as gnawing or burning, and 
is usually constant, but in some instances is paroxysmal, and often worse 
at night. On walking it may be very great; the knee is bent and the pa- 
tient treads on the toes, so as to relieve the tension on the nerve. In pro- 
tracted cases there may be much wasting of the muscles, but the reaction of 
degeneration can seldom be obtained. In these chronic cases cramp may 
occur and fibrillar contractions. Herpes may develop, but this is unusual. 
In rare instances the neuritis ascends and involves the spinal cord. 

The duration and course are extremely variable. As a rule it is an ob- 
stinate affection, lasting for months, or even, with slight remissions, for 
years. Relapses are not uncommon, and the disease may be relieved in one 
nerve only to appear in the other. In the severer forms the patient is bed- 
ridden, and such cases prove among the most distressing and trying which 
the physician is called upon to treat. 

In the diagnosis it is important, in the first place, to determine whether 
the disease is primary, or secondary to some affection of the pelvis or of 
the spinal cord. A careful rectal examination should be made, and, in 
women, pelvic tumor should be excluded. Lumbago may be confounded 
with it. Affections of the hip-joint arc easily distinguished by the absence 
of tenderness in the course of the nerve and ihe sense of pain on movement 
of the hip-joint or on pressure in the region of the trochanter. There are 
instances of sacro-iliac disease in which the patienl com plains of pain in 
the upper part of the thigh, which may sometimes radiate; but careful 
• 67 



1074 



DISEASES OF THE NERVOUS SYSTEM. 



examination will readily distinguish between the affections. Pressure on 
the nerve trunks of the cauda equina, as a rule, causes bilateral pain and 
disturbances of sensation, and, as double sciatica is rare, these circumstances 
always suggest lesion of the nerve roots. Between the severe lightning 
pains of tabes and sciatica the differences are usually well defined. 

Treatment. — The pelvic organs should be carefully and systematically 
examined. Constitutional conditions, such as rheumatism and gout, should 
receive appropriate treatment. In a few cases with pronounced rheumatic 
history, which come on acutely with fever, the salicylates seem to do good. 
In other instances they are quite useless. If there is a suspicion of syphilis, 
the iodide of potassium should be employed, and in gouty cases salines. 

Eest in bed with fixation of the limb by means of a long splint is a 
most valuable method of treatment in many cases, one upon which Weir 
Mitchell has specially insisted. I have known it to relieve, and in some 
instances to cure, obstinate and protracted cases which had resisted all 
other treatment. Hydrotherapy is sometimes satisfactory, particularly the 
warm baths or the mud baths. Many cases are relieved by a prolonged 
residence at one of the thermal springs. 

Antipyrin, antifebrin, and quinine, are of doubtful benefit. 

Local applications are more beneficial. The hot iron or the thermo- 
cautery or blisters relieve the pain temporarily. Deep injections into the 
nerves give great relief and may be necessary for the pain. It is best to use 
cocaine at first, in doses of from an eighth to a quarter of a grain. If the 
pain is unbearable morphia may be used, but it is a dangerous remedy in 
sciatica and should be withheld as long as possible. The disease is so pro- 
tracted, so liable to relapse, and the patient's morale so undermined by 
the constant worry and the sleepless nights, that the danger of contracting 
the morphia habit is very great. On no consideration should the patient 
be permitted to use the hypodermic needle himself. It is remarkable how 
promptly, in some cases, the injection of distilled water into the nerve will 
relieve the pain. Acupuncture may also be tried; the needles should be 
thrust deeply into the most painful spot for a distance of about 2 inches, 
and left for from fifteen to twenty minutes. The injection of chloroform 
into the nerve has also been recommended. 

Electricity is an uncertain remedy. Sometimes it gives prompt relief; 
in other cases it may be used for weeks without the slightest benefit. It 
is most serviceable in the chronic cases in which there is wasting of the 
legs, and should be combined with massage. The galvanic current should 
be used; a flat electrode should be placed over the sciatic notch, and a 
smaller one used along the course of the nerve and its branches. In very 
obstinate cases nerve-stretching may be employed. It is sometimes success- 
ful; but in other instances the condition recurs and is as bad as ever. 



ACUTE DELIRIUM. 



1075 



VII. GENEKAL AND FUNCTIONAL DISEASES. 

I. ACUTE DELIRIUM {BelVs Mania). 

Definition. — Acute delirium running a rapidly fatal course, with 
slight fever, and in which post mortem no lesions are found sufficient to 
account for the disease. 

Cases are reported by many old writers under the term brain fever or 
phrenitis. Bell, at the time Superintendent of the McLean Asylum, de- 
scribed it * accurately under the designation, " a form of disease resembling 
some advanced stages of mania and fever." 

The disease may set in abruptly or be preceded by a period of irrita- 
bility, restlessness, and insomnia. The mental symptoms develop with 
rapidity and may quickly reach a grade of the most intense frenzy. There 
are the wildest hallucinations and outbreaks of great violence. The pa- 
tient talks incessantly, but incoherently and unintelligibly. No sleep is 
obtained, and at last, worn out with the intensity of the muscular move- 
ments, the patient becomes utterly prostrated and assumes the sitting or 
recumbent posture. There may sometimes be definite salaam movements, 
and in a case which I saw at WestphaPs clinic the patient incessantly made 
motions as if working a pump handle. After a period of intense bodily 
excitement, lasting for from twenty-four to thirty-six hours or longer, the 
patient can be examined, and presents the conditions which Bell described 
as typho-mania. The temperature ranges from 102° to 104°, or even 
higher. The tongue is dry, the pulse rapid and feeble; sometimes there 
are seen on the skin bullae and pustules, and frequently sores from 
abrasion and self-inflicted injuries. Toward the close or, according to 
Spitzka, even during the development of the disease there may be lucid 
intervals. There may be petechias on the skin, and often there is marked 
congestion of the face and extremities. The duration of the disease is 
variable. Very acute cases may terminate within a week; others persist 
for two or even three weeks. The course of the disease is almost uniformly 
fatal. The anatomical condition is practically negative, or at any rate 
presents nothing distinctive. There is great venous engorgement of the 
vessels of the meninges and of the gray cortex. In two cases in which I 
made a careful microscopical examination of the gray matter there were 
perivascular exudation and leucocytes in the lymph sheaths and peri- 
gangliar spaces. In the inspection of fatal cases of acute delirium care- 
ful examination should be made of the lungs and ileum. It should be 
borne in mind that in a majority of the cases dying in this manner, 
there is engorgement of the bases of the lungs or even deglutition pneu- 
monia. 

The nature of the disease is quite unknown. Some of the cases sug- 
gest acute infection. Spitzka thinks that it is due to an autochthonous 
nerve poison. 



* American Journal of Insanity, 1849. 



1076 



DISEASES OF THE NERVOUS SYSTEM. 



Diagnosis. — There are several diseases which may present identical 
symptoms. As Bell remarks in his paper, the first glance in many cases 
suggests typhoid f ever, particularly when the patient is seen after the vio- 
lence of the mania has subsided. He gives two instances of this which were 
admitted from a general hospital. Enlargement of the spleen, the occur- 
rence of spots, and the history give clews for the separation of the cases; 
but there are instances in which it is at first impossible to decide. More- 
over, typhoid fever may set in with the most intense delirium. The exist- 
ence of fever is the most deceptive symptom, and its combination with 
delirium and dry tongue so commonly means typhoid fever that it is very 
difficult to avoid error. 

Acute pneumonia may come on with violent maniacal delirium and the 
pulmonary symptoms may be entirely masked. 

Occasionally acute uraemia sets in suddenly with intense mania, and 
finally subsides into a fatal coma. The condition of the urine and the ab- 
sence of fever would be important diagnostic features. 

The character of the delirium is quite different from that of mania a 
potu. It may be extremely difficult to differentiate acute delirium from 
certain cases of cortical meningitis occurring in connection with pneu- 
monia, ulcerative endocarditis or tuberculosis, or due to extension from 
disease of the ear. This sets in more frequently with a chill, and there 
may be convulsions. 

Treatment. — Even though bodily prostration is apt to come on early 
and be profound, in the case of a robust man free venesection might 
be tried. I have been criticised for this advice, but repeat it. It is 
not at all improbable that some of the many cases of mania in which 
Benjamin Eush let blood with such' benefit belonged to this class of affec- 
tions. Considering its remarkable calming influence in febrile delirium, 
the cold bath or the cold pack should be employed. Morphia and chloro- 
form may be administered and hyoscine and the bromides may be 
tried. Krafft-Ebing states that Solivetti has obtained good results by 
the use of ergotin. Unfortunately, as asylum reports show, the disease 
is almost uniformly fatal. 

II. PARALYSIS AGITANS 

(Parkinson's Disease ; Shaking Palsy). 

Definition. — A chronic affection of the nervous system, characterized 
by muscular weakness, tremors, and rigidity. 

Etiology. — Men are more frequently affected than women. It rarely 
occurs under forty, but instances have been reported in which the disease 
began about the twentieth year. It is by no means an uncommon affec- 
tion. Direct heredity is rare, but the patients often belong to families in 
which there are other nervous affections. Among exciting causes may be 
mentioned exposure to cold and wet, and business worries and anxieties. 
In some instances the disease has followed directly upon severe mental shock 
or trauma. Cases have been described after the specific fevers. Malaria 



PARALYSIS AGITANS. 



1077 



is believed by some to be an important factor, but of this there is no satis- 
factory evidence. 

Morbid Anatomy. — No constant lesions have been found. The 
similarity between certain of the features of Parkinson's disease and those 
of old age suggest that the affection may depend upon a premature senil- 
ity of certain regions of the brain. Our organs do not age uniformly, but 
in some, owing to hereditary disposition, the process may be more rapid 
than in others. " Parkinson's disease has no characteristic lesions, but on 
the other hand it is not a neurosis. It has for an anatomical basis the 
lesions of cerebro-spinal senility, and which only differ from those of true 
senility in their early onset and greater intensity " (Dubief). The im- 
portant changes are doubtless in the cerebral cortex. 

Symptoms. — The disease begins gradually, usually in one or other 
hand, and the tremor may be either constant or intermittent. With this 
may be associated weakness or stiffness. At first these symptoms may be 
present only after exertion. Although the onset is slow and gradual in 
nearly all cases, there are instances in which it sets in abruptly after fright 
or trauma. When well established the disease is very characteristic, and 
the diagnosis can be made at a glance. The four prominent symptoms 
are tremor, weakness, rigidity, and the attitude. 

Tremor. — This may be in the four extremities or confined to hands or 
feet; the head is not so commonly affected. The tremor is usually marked 
in the hands, and the thumb and forefinger display the motion made in the 
act of rolling a pill. At the wrist there are movements of pronation and 
supination, and, though less marked, of flexion and extension. The upper- 
arm muscles are rarely involved. In the legs the movement is most evident 
at the ankle-joint, and less in the toes than in the fingers. Shaking of the 
head is less frequent, but does occur, and is usually vertical, not rotatory. 
The rate of oscillation is about five per second. Any emotion exaggerates 
the movement. The attempt at a voluntary movement may check the 
tremor (the patient may be able to thread a needle), but it returns with 
increased intensity. The tremors cease, as a rule, during sleep, but persist 
when the muscles are at repose. The writing of the patient is tremulous 
and zigzag. 

Weakness. — Loss of power is present in all cases, and may occur even 
before the tremor, but is not very striking, as tested by the dynamometer, 
until the late stages. The weakness is greatest where the tremor is most 
developed. The movements, too, are remarkably slow. There is rarely 
complete loss of power. 

Rigidity may early be expressed in a slowness and stiffness in the vol- 
untary movements, which are performed with some effort and difficulty, 
and all the actions of the patient are deliberate. This rigidity is in all the 
muscles, and leads ultimately to the characteristic 

Attitude and Gait. — The head is bent forward, the back is bowed, and 
the arms are held away from the body and are somewhat flexed at the 
elbow-joints. The face is expressionless, and the movements of the lips 
are slow. The eyebrows are elevated, and the whole expression is immobile 
X)T mask-like, the so-called Parkinson's mask. The voice, as pointed out 



1078 



DISEASES OF THE NERVOUS SYSTEM. 



by Buzzard, is apt to be shrill and piping, and there is often a hesitancy in 
beginning a sentence; then the words are uttered with rapidity, as if the 
patient was in a hurry. This is sometimes in striking contrast to the scan- 
ning speech of insular sclerosis. The fingers are flexed and in the position 
assumed when the hand is at rest; in the late stages they cannot be ex- 
tended. Occasionally there is overextension of the terminal phalanges. 
The hand is usually turned toward the ulnar side and the attitude some- 
what resembles that of advanced cases of rheumatoid arthritis. In the 
late stages there are contractures at the elbows, knees, and ankles. The 
movements of the patient are characterized by great deliberation. He rises 
from the chair slowly in the stooping attitude, with the head projecting 
forward. In attempting to walk the steps are short and hurried, and, as 
Trousseau remarks, he appears to be running after his centre of gravity. 
This is termed festination or propulsion, in contradistinction to a peculiar 
gait observed when the patient is pulled backward, when he makes a num- 
ber of steps and would fall over if not prevented — retropulsion. 

The reflexes are normal in most cases, but in a few they are exaggerated. 

Of sensory disturbances Charcot has noted abnormal alterations in the 
temperature sense. The patient may complain of subjective sensations of 
heat, either general or local — a phenomenon which may be present on one 
side only and associated with an actual increase of the surface temperature, 
as much as 6° F. (Growers). In other instances, patients complain of cold. 
Localized sweating may be present. The mental condition rarely shows any 
change. 

Variations in the Symptoms. — The tremor may be absent, but the rigid- 
ity, weakness, and attitude are sufficient to make the diagnosis. The dis- 
ease may be hemiplegic in character, involving only one side or even one 
limb. Usually these are but stages of the disease. 

Diagnosis.' — In well-developed cases the disease is recognized at a 
glance. The attitude, gait, stiffness, and mask-like expression are points 
of as much importance as the oscillations, and usually serve to separate 
the cases from senile and other forms of tremor. Disseminated sclerosis 
develops earlier, and is characterized by the nystagmus, and the scanning 
speech, and does not present the attitude so constant in paralysis agitans. 
Yet Schultze and Sachs have reported cases in which the signs of multiple 
sclerosis have been associated with those of paralysis. The hemiplegic 
form might be confounded with post-hemiplegic tremor, but the history, 
the mode of onset, and the greatly increased reflexes would be sufficient to 
distinguish the two. The Parkinsonian face is of great importance in the 
diagnosis of the obscure and anomalous forms. 

The disease is incurable. Periods of improvement may occur, but the 
tendency is for the affection to proceed progressively downward. It is a 
slow, degenerative process and the cases last for years. 

Treatment.- — There is no method which can be recommended as satis- 
factory in any respect. Arsenic, opium, and hyoscyamine may be tried, but 
the friends of the patient should be told frankly that the disease is incur- 
able, and that nothing can be done except to attend to the physical com- 
forts of the patient. Regulated and systematized exercises should be car-, 
ried out. 



ACUTE CHOREA. 



1079 



Other Forms of Tremor. 

(a) Simple Tremor. — This is occasionally found in persons in whom it 
is impossible to assign any cause. It may be transient or persist for an 
indefinite time. It is often extremely slight, and is aggravated by all causes 
which lower the vitality. 

(b) Hereditary Tremor. — C. L. Dana has reported remarkable cases of 
hereditary tremor. It occurred in all the members of one family, and be- 
ginning in infancy continued without producing any serious changes. 

(c) Senile Tremor. — With advancing age tremulousness during muscular 
movements is extremely common, but is rarely seen under seventy. It is 
always a fine tremor, which begins in the hands and often extends to the 
muscles of the neck, causing slight movement of the head. 

(d) Toxic tremor is seen chiefly as an effect of tobacco, alcohol, lead, or 
mercury; more rarely in arsenical or opium poisoning. In elderly men 
who smoke much it may be entirely due to the tobacco. One of the com- 
monest forms of this is the alcoholic tremor, which occurs only on move- 
ment and has considerable range. Lead tremor is considered under lead 
poisoning, of which it constitutes a very important symptom. 

(e) Hysterical tremor, which usually occurs under circumstances which 
make the diagnosis easy, will be considered in the section on hysteria. 

III. ACUTE CHOREA 

{Sydenham's Chorea ; St. Vitus' 's Dance). 

Definition. 1 — A disease chiefly affecting children, characterized by 
irregular, involuntary contraction of the muscles, a variable amount of 
psychical disturbance, and a remarkable liability to acute endocarditis. 

We shall speak here only of Sydenham's chorea. Senile chorea, chronic 
chorea, the prehemiplegic and post hemiplegic forms, and rhythmic chorea 
are totally different affections. 

Etiology. — Sex. — Of 554 cases which I have analyzed from the Phila- 
delphia Infirmary for Diseases of the Nervous System, 71 per cent were in 
females and 29 per cent in males. After puberty the percentage in females 
increases. 

Age. — The disease is most common between the ages of five and fifteen. 
Of 522 cases, 380 occurred in this period. It is more common in the lower 
classes, and is rare among the negroes and native races of this continent. 
Morris J. Lewis has shown that the cases are most numerous when the 
mean relative humidity is excessive and the barometric pressure low. 

Rheumatism. — A causal relationship between rheumatism and chorea 
has been claimed by many since the time of Bright. The English and 
French writers maintain the closeness of this connection; on the other 
hand, German authors, as a rule, regard the connection as by no means very 
close. Of 554 cases which I have analyzed, in L5.5 per cenl there was a 
history of rheumatism in the family. In 88 cases, 15.8 per cent, there 
was a history of articular swelling, acute or subacute. In 33 cases there 



1080 



DISEASES OF THE NERVOUS SYSTEM. 



were pains, sometimes described as rheumatic, in various parts, but not 
associated with joint trouble. If we regard all such cases as rheumatic and 
add them to those with manifest articular trouble, the percentage is raised 
to nearly 21. 

We find two groups of cases in which acute arthritis is present in 
chorea. In one, the arthritis antedates by some months or years the onset 
of the chorea, and does not recur before or during the attack. In the 
other group, the chorea sets in with or follows immediately upon the acute 
arthritis. In some instances it is impossible to decide whether the joint 
symptoms or the movements have appeared first. It is difficult to differ- 
entiate the cases of irregular pains without definite joint affection. It is 
probable that many of them are rheumatic, and yet I think it would be a 
mistake to regard as such all cases in children in which there are complaints 
of vague pains in the bones or muscles — so-called growing pains. It should 
never be forgotten, however, that a slight articular swelling may be the 
sole manifestation of rheumatism in a child — so slight, indeed, that the 
disease may be entirely overlooked. 

Heart-disease. — Endocarditis is believed by some writers to be the cause 
of the disease. The particles of fibrin and vegetations from the valves 
pass as emboli to the cerebral vessels. On this view, which we shall discuss 
later, chorea is the result of an embolic process occurring in the course of 
a rheumatic endocarditis. 

Infectious Diseases. — Scarlet fever with arthritic manifestations may 
be a direct antecedent. Sturges states that a history of previous whooping- 
cough occurs more frequently in choreic than in other children, but I find 
no evidence of this in the Infirmary records. With the exception of rheu- 
matic fever, there is no intimate relationship between chorea and the acute 
diseases incident to childhood. It may be noted in contrast to this that 
the so-called canine chorea is a common sequel of distemper. Chorea has 
been known to develop in the course of an acute pyaemia, and to follow 
gonorrhoea and puerperal fever. 

Anmmia is less often an antecedent than a sequence of chorea, and 
though cases develop in children who are anaemic and in poor health, this 
is by no means the rule. Chorea may develop in chlorotic girls at puberty. 

Pregnancy. — A choreic patient may become pregnant; more frequently 
the disease occurs during pregnancy; sometimes it develops post partum. 
Buist, of Dundee (Trans. Edin. Obs. Soc, 1895), has tabulated carefully 
the recorded cases to that date. Of 226 cases, in 6 the chorea preceded 
the pregnancy; in 105 it occurred during the pregnancy; in 31 in recur- 
rent pregnancies; 45 cases terminated fatally, and in 16 cases the chorea 
developed post partum. The alleged frequency in illegitimate primiparae is 
not borne out by his figures. Beginning in the first three months were 
108 cases, in the second three months 70 cases, in the last three months 
25 cases. The disease is often severe, and maniacal symptoms may de- 
velop. 

A tendency to the disease is found in certain families. In 80 cases 
there was a history of attacks of chorea in other members. In one instance 
both mother and grandmother had been affected. . High-strung, excitable, 



ACUTE CHOREA. 



1081 



nervous children are especially liable to the disease. Fright is considered 
a frequent cause, but in a large majority of the cases no close connection 
exists between the fright and the onset of the disease. Occasionally the 
attack sets in at once. Mental worry, trouble, a sudden grief, or a scold- 
ing may apparently be the exciting cause. The strain of education, par- 
ticularly in girls during the third hemidecade, is a most important factor 
in the etiology of the disease. Bright, intelligent, active-minded girls 
from ten to fourteen, ambitious to do well at school, often stimulated in 
their efforts by teachers and parents, form a large contingent of the cases 
of chorea in hospital and private practice. Sturges has called special at- 
tention to this school-made chorea as one serious evil in our modern method 
of forced education. Imitation, which is mentioned as an exciting cause, 
is extremely rare, and does not appear to have influenced the onset in a 
single case in the Infirmary records. 

The disease may rapidly follow an injury or a slight surgical operation. 
Eeflex irritation was believed to play an important role in the disease, 
particularly the presence of worms or genital irritation; but I have met with 
no instance in which the disease could be attributed to either of these 
causes. Local spasm, particularly of the face — the habit chorea of Mitchell 
— may be associated with irritation in the nostrils and adenoid growths in 
the vault of the pharynx, as pointed out by Jacobi. 

It has been claimed by Stevens that ocular defects lie at the basis of 
many cases of chorea, and that with the correction of these the irregular 
movements disappear. The investigations of De Schweinitz show that 
ocular defects do not occur in greater proportion in choreic than in other 
children. A majority of the cases in which operation has been followed by 
relief have been instances of tic, local or general. 

Morbid Anatomy and Pathology. — No constant lesions have 
been found in the nervous system in acute chorea. Vascular changes, 
such as hyaline transformation, exudation of leucocytes, minute haemor- 
rhages, and thrombosis of the smaller arteries, have been described. 

Embolism of the smaller cerebral vessels has been found, and there are 
on record 7 cases of embolism of the central artery of the retina (H. M. 
Thomas, 1901). Based on the presence of emboli, Kirkes and others have 
supported what is known as the embolic theory of the disease. Endocar- 
ditis is by far the most frequent lesion in Sydenham's chorea. With no 
disease, not excepting rheumatism, is it so constantly associated. I have 
collected from the literature (to July, 189-4) the records of 73 autopsies; 
there were 62 with endocarditis.* The endocarditis is usually of the sim- 
ple variety, but the ulcerative form has occasionally been described. 

We are still far from a solution of all the problems connected with 
chorea. Unfortunately, the word has been used to cover a series of totally 
diverse disorders of movement, so that there are still excellent observers 
who hold that chorea is only a symptom, and is not to be regarded as an 
etiological unit. The chorea of childhood, the disease which Sydenham 
described, presents, however, characteristics so unmistakable that it must 



* Osier, Chorea and Choreiform Affections, 1894. 



1082 



DISEASES OF THE NERVOUS SYSTEM. 



be regarded as a definite, substantive affection. We cannot discuss fully, 
but only indicate briefly, certain of the theories which have been advanced 
with regard to it. The most generally accepted view is that it is a func- 
tional brain disorder affecting the nerve-centres controlling the motor ap- 
paratus, an instability of the nerve-cells, brought about, one supposes by 
hyperemia, another by anaemia, a third by psychical influences, a fourth 
bv irritation, centric or peripheric. Of the actual nature of this derange- 
ment we know nothing, nor, indeed, whether the changes are primary and 
the result of a faulty action of the cortical cells or whether the impulses 
are secondarily disturbed in their course down the motor path. The pre- 
dominance of the disease in females, and its onset at a time when the 
education of the brain is rapidly developing, are etiological facts which 
Sturges has urged in favor of the view that chorea is an expression of 
functional instability of the nerve-centres. 

The embolic theory originally advanced by Kirkes has a solid basis of 
fact, but it is not comprehensive enough, as all of the cases cannot be 
brought within its limits. There are instances without endocarditis and 
without, so far as can be ascertained, plugging of cerebral vessels; and 
there are also cases with extensive endocarditis in which the histological 
examination of the brain, so far as embolism is concerned, was negative. 
In favor of the embolic view is the experimental production in animals of 
chorea by Eosenthal, and later by Money, by injecting fine particles into 
the carotids. 

Lately, as indeed might be expected, chorea has been regarded as an 
infectious disease. Nothing definite has yet been determined. In favor of 
this view it has been urged, as it is impossible to refer the chorea to endo- 
carditis or the endocarditis in all cases to rheumatism, that both have their 
origin in a common cause, some infectious agent, which is capable also, 
in persons predisposed, of exciting articular disease. Cases have been re- 
ported in scarlet fever with arthritic manifestations, in puerperal fever, and 
rheumatism, also after gonorrhoea, and such facts are suggestive at least 
of the association of the disease with infective processes. Possibly, as has 
been suggested by some writers, the paralytic conditions associated with 
chorea may be analogous to those which occur in typhoid and certain of 
the infectious diseases. On the other hand, there are conditions extremely 
difficult to harmonize with this view. The prominent psychical element 
is certainly one of the most serious objections, since there can be no doubt 
that ordinary chorea may rapidly follow a fright or a sudden emotion. 

Symptoms. — Three groups of cases may be recognized — the mild, 
severe, and maniacal chorea. 

Mild Chorea. — In this the affection of the muscles is slight, the speech 
is not seriously disturbed, and the general health not impaired. Premoni- 
tory symptoms are shown in restlessness and inability to sit still, a condi- 
tion well characterized by the term " fidgets." There are emotional dis- 
turbances, such as crying spells, or sometimes night-terrors. There may 
be pains in the limbs and headache. Digestive disturbances and anaemia 
may be present. A change in the temperament is frequently noticed, and 
a docile, quiet child may become cross and irritable. After these symp- 



ACUTE CHOKEA. 



1083 



toms have persisted for a week or more the characteristic involuntary 
movements begin, and are often first noticed at the table, when the child 
spills a tumbler of water or upsets a plate. There may be only awkwardness 
or slight incoordination of voluntary movements, or constant irregular 
clonic spasms. The jerky, irregular character of the movements differen- 
tiates them from almost every other disorder of motion. In the mild cases 
only one hand, or the hand and face, are affected, and it may not spread 
to the other side. 

In the second grade, the severe form, the movements become general 
and the patient may be unable to get about or to feed or undress herself, 
owing to the constant, irregular, clonic contractions of the various muscle 
groups. The speech is also affected, and for days the child may not be 
able to talk. Often with the onset of the severer symptoms there is loss 
of power on one side or in the limb most affected. 

The third and most extreme form, the so-called maniacal chorea, or 
chorea insaniens, is truly a terrible disease, and may develop out of the 
ordinary form. These cases are more common in adult women and may 
develop during pregnancy. 

Chorea begins, as a rule, in the hands and arms, then involves the face, 
and subsequently the legs. The movements may be confined to one side 
— hemichorea. The attack begins oftenest on the right side, though oc- 
casionally it is general from the outset. One arm and the opposite leg 
may be involved. In nearly one fourth of the cases speech is affected; 
this may amount only to an embarrassment or hesitancy, but in other in- 
stances it becomes an incoherent jumble. In very severe cases the child 
will make no attempt to speak. The inability is in articulation rather than 
in phonation. Paroxysms of panting and of hard expiration may occur, 
or odd sounds may be produced. As a rule the movements cease during 
sleep. 

A prominent symptom is muscular weakness, usually no more than a 
condition of paresis. The loss of power is slight, but the weakness may 
be shown by an enfeebled grip or by a dragging of the leg or limping. In 
his original account Sydenham refers to the " unsteady movements of one 
of the legs, which the patient drags." There may be extreme paresis with 
but few movements — the paralytic chorea of Todd. Occasionally a local 
paralysis or weakness remains after the attack. 

It is doubtful whether choreic spasms extend to the muscles of organic 
life. The rapid action and disturbed rhythm of the heart present nothing 
peculiar to the disease, and there is no support for the view that irregular 
contractions occur in the papillary muscles. 

Heart Symptoms. — Neurotic. — As so many of the subjects of chorea are 
nervous girls, it is not surprising that a common symptom is n rapidly acting 
heart. Irregularity, however, is not so special a feature in chorea as ra- 
pidity. The patients seldom complain of pain about the heart. 

Hcemic Murmurs. — With anaemia and debility, not uncommon assoc- 
iates of chorea in the third or fourth week, we find a corresponding 
cardiac condition. The impulse is diffuse, perhaps wavy in thin children. 
The carotids throb visibly, and in the recumbent posture there may be 



1084 



DISEASES OF THE NERVOUS SYSTEM. 



pulsation in the cervical veins. On auscultation a systolic murmur is 
heard at the base, perhaps, too, at the apex, soft and blowing in quality. 

Endocarditis. — As in rheumatism, so in chorea, acute valvulitis rarely 
gives evidence of its presence by symptoms. It must be sought, and cliir- 
ical experience has shown that it is usually associated with murmurs at 
one or other of the cardiac orifices. 

For the guidance of the practitioner the following statements may be 
made: 

(1) In thin, nervous children a systolic murmur of soft quality is ex- 
tremely common at the base, with accentuation of the second sound, par- 
ticularly at the second left costal cartilage, and is probably of no moment. 

(2) A systolic murmur of maximum intensity at the apex, and heard 
also along the left sternal margin, is not uncommon in anaemic, en- 
feebled states, and does not necessarily indicate either endocarditis or insuf- 
ficiency. 

(3) A murmur of maximum intensity at apex, with rough quality, and 
transmitted to axilla or angle of scapula, indicates an organic lesion of 
the mitral valve, and is usually associated with signs of enlargement of the 
heart. 

(4) When in doubt it is much safer to trust to the evidence of eye 
and hand than to that of the ear. If the apex beat is in the normal posi- 
tion, and the area of dulness not increased vertically or to the right of the 
sternum, there is probably no serious valvular disease. 

(5) The endocarditis of chorea is almost invariably of the simple or 
warty form, and in itself is not dangerous; but it is apt to lead to those 
sclerotic changes in the valve which produce incompetency. Of 140 pa- 
tients examined more than two years after the attack,* I found the heart 
normal in 51; in 17 there was functional disturbance, and 72 presented 
signs of organic heart-disease. 

(6) Pericarditis is an occasional complication of chorea, usually in cases 
with well-marked rheumatism. 

Sensory Disturbances. — Pain in the affected limbs is not common. . Oc- 
casionally there is soreness on pressure. There are cases, usually of hemi- 
chorea, in which pain in the limbs is a marked symptom. Weir Mitchell 
has spoken of these as painful choreas. Tender points along the lines of 
emergence of the spinal nerves or along the course of the nerves of the 
limbs are rare. 

Psychical disturbances are common, though in a majority of the cases 
slight in degree. Irritability of temper, marked wilfulness, and emotional 
outbreaks may indicate a complete change in the character of the child. 
There is deficiency in the powers of concentration, the memory is en- 
feebled, and the aptitude for study is lost. Earely there is progressive 
impairment of the intellect with termination in actual dementia. Acute 
melancholia has been described (Edes). Hallucinations of sight and hear- 
ing may occur. Patients may behave in an odd and strange manner and 
do all sorts of meaningless acts. By far the most serious manifestation of 



* Monograph on Chorea, 1894. 



ACUTE CHOREA. 



1085 



this character is the maniacal delirium, occasionally associated with the 
very severe cases — chorea insaniens. Usually the motor disturbance in 
these cases is aggravated, but it has been overlooked and patients have 
been sent to an asylum. 

The psychical element in chorea is apt to be neglected by the practi- 
tioner. It is always a good plan to tell the parents that it is not the 
muscles alone of the child which are affected, but that the general irrita- 
bility and change of disposition, so often found, really form part of the 
disease. 

The condition of the reflexes in chorea is usually normal. Trophic 
lesions rarely occur in chorea unless, as some writers have done, we regard 
the joint troubles as arthropathies occurring in the course of a cerebro- 
spinal disease. 

Fever is not, as a rule, present in chorea unless complications exist. 
There may be the most intense and violent movements without any rise 
of temperature. I have seen instances, however, in which without appar- 
ently any visceral or articular disturbances there was slight daily fever. 
H. A. Hare states that in monochorea the temperature on the affected 
side may be elevated; but this is not an invariable rule. Fever is found 
with an acute arthritis, when there is marked endocarditis or pericarditis, 
though the former may certainly occur with little if any rise in tempera- 
ture, and in the cases of maniacal chorea, in which the fever may range 
from 102° to 104°. 

Cutaneous Affections. — The pigmentation, which is not uncommon, is 
due to the arsenic. Herpes zoster occasionally occurs. Certain skin erup- 
tions, usually regarded as rheumatic in character, are not uncommon. 
Erythema nodosum has been described and I have seen several cases with 
a purpuric urticaria. There may, indeed, be the more aggravated condi- 
tion of rheumatic purpura, known as Schonlein's peliosis rheumatica. Sub- 
cutaneous fibrous nodules, which have been noted by English observers in 
many cases of chorea, associated with rheumatism, are extremely rare in 
this country. 

Duration and Termination. — From eight to ten weeks is the av- 
erage duration of an attack of moderate severity. Chronic chorea rarely 
follows the minor disease which we have been considering. The cases de- 
scribed under this designation in children are usually instances of cerebral 
sclerosis or Friedreich's ataxia; but occasionally an attack which has come 
on in the ordinary way persists for months or years, and recovery ulti- 
mately takes place. A slight grade of chorea, particularly noticeable under 
excitement, may persist for months in nervous children. 

The tendency of chorea to recur has been noticed by all writers since 
Sydenham first made the observation. Of 410 cases analyzed for this pur- 
pose, 240 had one attack, 110 had two attacks, 35 three attacks, 10 four 
attacks, 12 five attacks, and 3 six attacks. The recurrence is apt to be 
vernal. 

Eecovery is the rule in children. The statistics of out-patients' depart- 
ments are not favorable for determining the mortality. A reliable esti- 
mate is that of the Collective Investigation Committee of the British Medi- 



1086 



DISEASES OF THE NERVOUS SYSTEM. 



eal Association, in which 9 deaths were reported among 439 cases, about 
2 per cent. 

The paralysis rarely persists. Mental dulness may be present for a 
time, but usually passes away; permanent impairment of the mind is an 
exceptional sequence. 

Diagnosis. — There are few diseases which present more characteristic 
features, and in a majority of instances the nature of the trouble is recog- 
nized at a glance; but there are several affections in children which may 
simulate and be mistaken for it. 

(a) Multiple and diffuse cerebral sclerosis. The cases are often mis- 
taken for ordinary chorea, and have been described in the literature as chorea 
spastica. 

There are doubtless chronic changes in the cortex. As a rule, the 
movements are readily distinguishable from those of true chorea, but the 
simulation is sometimes very close; the onset in infancy, the impaired in- 
telligence, increased reflexes and in some instances rigidity, and the chronic 
course of the disease, separate them sharply from true chorea. 

(b) Friedreich's ataxia. Cases of this well-characterized disease were 
formerly classed as chorea. The slow, irregular, incoordinate movements, 
the scoliosis, the scanning speech, the early talipes, the nystagmus, and the 
family character of the disease are points which should render the diag- 
nosis easy. 

(c) In rare cases the paralytic form of chorea may be mistaken for 
polio-myelitis or, when ^oth legs are affected, for paraplegia of spinal 
origin; but this can only be the case when the choreic movements are very 
slight. 

(d) Hysteria may simulate chorea minor most closely, and unless there 
are other manifestations it may be impossible to make a diagnosis. Most 
commonly, however, the movements in the so-called hysterical chorea are 
rhythmic and differ entirely from those of ordinary chorea. 

(e) As mentioned above, the mental symptoms in maniacal chorea may 
mask the true nature of the disease and patients have even been sent to 
the asylum. 

Treatment. — Abnormally bright, active-minded children belonging 
to families with pronounced neurotic taint should be carefully watched 
from the ages of eight to fifteen and not allowed to overtax their mental 
powers. So frequently in children of this class does the attack of chorea 
date from the worry and stress incident to school examinations that the 
competition for prizes or places should be emphatically forbidden. 

The treatment of the attack consists largely in attention to hygienic 
measures, with which alone, in time, a majority of the cases recover. Par- 
ents should be told to scan gently the faults and waywardness of choreic 
children. The psychical element, strongly developed in so many cases, 
is best treated by quiet and seclusion. The child should be confined to 
bed in the recumbent posture, and mental as well as bodily quiet enjoined. 
In private practice this is often impossible, but with well-to-do patients 
the disease is always serious enough to demand the assistance of a skilled 
nurse. Toys and dolls should not be allowed at first, for the child should 



ACUTE CHOREA. 



1087 



be kept amused without excitement. The rest allays the hyper-excitabil- 
ity and reduces to a minimum the possibility of damage to the valve seg- 
ments should endocarditis exist. Time and again have I seen very severe 
cases which had resisted treatment for weeks outside a hospital become 
quiet and the movements subside after two or three days of absolute rest 
in bed. 

The child should be kept apart from other children and, if possible, 
from other members of the family, and should see only those persons 
directly concerned with the nursing of the case. In the latter period of 
the disease daily rubbings may be resorted to with great benefit. 

The medical treatment of the disease is unsatisfactory; with the ex- 
ception of arsenic, no remedy seems to have any influence in controlling 
the progress of the affection. Without any specific action, it certainly 
does good in many cases, probably by improving the general nutrition. 
It is conveniently given in the form of Fowler's solution, and the good 
effects are rarely seen until maximum doses are taken. It may be given 
as Martin originally advised (1813); he began "with five drops and in- 
creased one drop every day, until it might begin to disagree with the stom- 
ach or bowels." When the dose of 15 minims is reached, it may be con- 
tinued for a week, and then again increased, if necessary, every day or two, 
until physiological effects are manifest. On the occurrence of these the 
drug should be stopped for three or four days. The practice of resuming 
the administration with smaller doses is rarely necessary, as tolerance is usu- 
ally established and we can begin with the dose which the child was taking 
when the symptoms of saturation occurred. I have frequently given as 
much as 25 minims three times a day. Usually the signs of saturation are 
trivial but plain, but in very rare instances more serious symptoms develop. 
A fatal arsenical neuritis followed in the case of a child, aged eight, who 
took seven drops of Fowler's solution three times a day for ten days, then 
stopped for a week, and then took seven drops three times a day for four- 
teen days (Cary Gamble, Jr.). 

Of other medicines, strychnine, the zinc compounds, nitrate of silver, 
bromide of potassium, belladonna, chloral, and especially cimicifuga, have 
been recommended, and may be tried in obstinate cases. 

For its tonic effect electricity is sometimes useful; but it is not neces- 
sary as a routine treatment. The question of gymnastics is an important 
one. Early in the disease, when the movements are active, they are not 
advisable; but during convalescence carefully graduated exercises are un- 
doubtedly beneficial. It is not well, however, to send a choreic child to a 
school gymnasium, as the stimulus of the other children and the excite- 
ment of the romping, violent play are very prejudicial. 

Other points in treatment may be mentioned. It is important to regu- 
late the bowels and to attend carefully to the digestive functions. For the 
anemia so often present preparations of iron are indicated. 

In the severe cases with incessant movements, sleeplessness, dry tongue, 
and delirium, the important indication is to procure rest, for which pur- 
pose chloral may be freely given, and, if necessary, morphia. Chloroform 
inhalations may be necessary to control the intensity of the paroxysms, 



1088 



DISEASES OF THE NERVOUS SYSTEM. 



but the high rate of mortality in this class of cases illustrates how often 
our best endeavors are fruitless. The wet pack is sometimes very soothing 
and should be tried. As these patients are apt to sink rapidly into a low 
typhoid state with heart weakness, a supporting treatment is required from 
the outset. 

Cases are found now and then which drag on from month to month 
without getting either better or worse and resist all modes of treatment. 
Change of air and scene is sometimes followed by rapid improvement, and 
in these cases the treatment by rest and seclusion should always be given a 
full trial. 

In all cases care should be taken to examine the nostrils, and glaring 
ocular defects should be properly corrected either by glasses or, if neces- 
sary, by operation. 

After the child has recovered from the attack, the parents should be 
warned that return of the disease is by no means infrequent, and is par- 
ticularly liable to follow overwork at school or debilitating influences of 
any kind. These relapses are apt to occur in the spring. Sydenham ad- 
vised purging in order to prevent the vernal recurrence of the disease. 



IV. OTHER AFFECTIONS DESCRIBED AS CHOREA. 

(a) Chorea Major ; Pandemic Chorea.' — The common name, St. Vitus's 
dance, applied to chorea has come to us from the middle ages, when under 
the influence of religious fervor there were epidemics characterized by great 
excitement, gesticulations, and dancing. For the relief of these symptoms, 
when excessive, pilgrimages were made, and in the Ehenish provinces, par- 
ticularly to the Chapel of St. Vitus in Zebern. Epidemics of this sort 
have occurred also during this century, and descriptions of them among the 
early settlers in Kentucky have been given by Eobertson and Yandell. 
It was unfortunate that Sydenham applied the term chorea to an affection 
in children totally distinct from this chorea major, which is in reality an 
hysterical manifestation under the influence of religious excitement. 

(b) Habit Spasm (Habit Chorea) ; Convulsive Tic (of the French). 

Two groups of cases may be recognized under the designation of habit 
spasm — one in which there are simply localized spasmodic movements, and 
the other in which, in addition to this, there are explosive utterances and 
psychical symptoms, a condition to which French writers have given the 
name tic convulsif. 

(1) Habit Spasm. — This is found chiefly in childhood, most frequently 
in girls from seven to fourteen years of age (Mitchell). In its simplest 
form there is a sudden, quick contraction of certain of the facial muscles, 
such as rapid winking or drawing of the mouth to one side, or the neck 
muscles are involved and there are unilateral movements of the head. 
The head is given a sudden, quick shake, and at the same time the eyes 
wink. A not infrequent form is the shrugging of one shoulder. The 
grimace or movement is repeated at irregular intervals, and is much aggra- 
vated by emotion. A short inspiratory sniff is not an uncommon symp- 



OTHER AFFECTIONS DESCRIBED AS CHOREA. 



1089 



torn. The cases are found most frequently in children who are " out of 
sorts/' or who have been growing rapidly, or who have inherited a tend- 
ency to neurotic disorders. Allied to or associated with this are some of 
the curious tricks of children. A boy at my clinic was in the habit every 
few moments of putting the middle finger into the mouth, biting it, and 
at the same time pressing his nose with the forefinger. Hartley Cole- 
ridge is said to have had a somewhat similar trick, only he bit his arm. 
In all these cases the habits of the child should be examined carefully, the 
nose and vault of the pharynx thoroughly inspected, and the eyes accurately 
tested. As a rule the condition is transient, and after persisting for a few 
months or longer gradually disappears. Occasionally a local spasm persists 
— twitching of the eyelids, or the facial grimace. 

(2) Impulsive Tic (Gilles de la Tourette's Disease). — This remarkable 
affection, often mistaken for chorea, more frequently for habit spasm, is 
really a psychosis allied to hysteria, though in certain of its aspects it has 
the features of monomania. The disease begins, as a rule, in young chil- 
dren, occurring as early as the sixth year, though it may develop after pu- 
berty. There is usually a markedly neurotic family history. The special 
features of the complaint are: 

(a) Involuntary muscular movements, usually affecting the facial or 
brachial muscles, but in aggravated cases all the muscles of the body may 
be involved and the movements may be extremely irregular and violent. 

(b) Explosive utterances, which may resemble a bark or an inarticulate 
cry. A word heard may be mimicked at once and repeated over and over 
again, usually with the involuntary movements. To this the term ecJio- 
lalia has been applied. A much more distressing disturbance in these 
cases is coprolalia, or the use of bad language. A child of eight or ten 
may shock its mother and friends by constantly using the word damn 
when making the involuntary movements, or by uttering all sorts of ob- 
scene words. Occasionally actions are mimicked — echokinesis. 

(c) Associated with some of these cases are curious mental disturbances; 
the patient becomes the subject of a form of obsession or a fixed idea. In 
other cases the fixed idea takes the form of the impulse to touch objects, 
or it is a fixed idea about words — onomatomania — or the patient may feel 
compelled to count a number of times before doing certain actions — arith- 
momania. 

The disease is well marked and readily distinguished from ordinary 
chorea. The movements have a larger range and are explosive in charac- 
ter. Tourette regards the coprolalia as the most distinctive feature of the 
disease. The prognosis is doubtful. I have, however, known recovery to 
follow. 

(c) Saltatory Spasm (Latah; Myriachit; Jumpers). — Bamberger has de- 
scribed a disease in which when the patient attempted to stand there were 
strong contractions in the leg muscles, which caused a jumping or spring- 
ing motion. This occurs only when the patient attempts to stand. The 
affection has occurred in both men and women, more frequently in the 
former, and the subjects have usually shown marked neurotic tendencies. 
In many cases the condition has been transitory; in others it has persisted 



1090 



DISEASES OF THE XERVOUS SYSTEM. 



for years. Remarkable affections similar to this in certain points occur 
as a sort of endemic neurosis. One of the most striking of these occurs 
among the " jumping Frenchmen " of Maine and Canada. As described 
b} T Beard and Thornton, the subjects are liable on any sudden emotion to 
jump violently and utter a loud cry or sound, and will obey any command 
or imitate any action without regard to its nature. The condition of 
echolalia is present in a marked degree. The " jumping " prevails in cer- 
tain families. 

A very similar disease prevails in parts of Eussia and in J ava, where it is 
known by the names of myriachit and latah, the chief feature of which is 
mimicry by the patient of everything he sees or hears. 

(d) Chronic Chorea {Huntington's Chorea). — An affection characterized 
by irregular movements, disturbance of speech, and gradual dementia. It 
is frequently hereditary. The disease has no connection with Sydenham's 
chorea, and it is unfortunate that the term was applied to it. It was be- 
scribed by Huntington, of Pomeroy, Ohio, at the time a practitioner on 
Long Island, and he gave in three brief paragraphs the salient points in 
connection with the disease — namely, the hereditary nature, the associa- 
tion with psychical troubles, and the late onset — between the thirtieth and 
fortieth years. The disease seems common in this country, and many 
cases have been reported by Clarence King, Sinkler, and others. I have 
seen it in two Maryland families within the past few years. Under the 
term chronic chorea may be grouped the hereditary form and the cases 
which come on without family disposition, either at middle life or, more 
commonly, in the aged — senile chorea. It is doubtful whether the cases 
in children with chronic choreiform movements, often with mental weak- 
ness and spastic condition of the legs, should go into this category. 

The hereditary character of the disease is very striking; it has been 
traced through four or five generations. Huntington's father and grand- 
father, also physicians, had treated the disease in the family which he de- 
scribed. Osborn, of East Hampton, L. I., writes (Jan. 28th, 1898) that the 
disease still continues to recur in certain families described by Huntington, 
as it has done, so it is said, for fully two centuries. An identical affection 
occurs without any hereditary disposition. The age of onset is late, rarely 
before the thirtieth or the thirty-fifth year. 

The symptoms are very characteristic. The irregular movements are 
usually first seen in the hands, and the patient has slight difficulty in per- 
forming delicate manipulations or in writing. When well established the 
movements are disorderly, irregular, incoordinate rather than choreic, and 
have not the sharp, brusque motion of Sydenham's chorea. In the face 
there are slow, involuntary grimaces. In a well-developed case the gait 
is irregular, swaying, and somewhat like that of a drunken man. The 
speech is slow and difficult, the syllables are badly pronounced and indis- 
tinct, but not definitely staccato. The mental impairment leads finally to 
dementia. 

Very few autopsies have been made. Xo characteristic lesions have 
been found. Atrophy of the convolutions, chronic meningoencephalitis, 
and vascular changes have usually been present, the conditions which one 



INFANTILE CONVULSIONS. 



1091 



would expect to find in chronic dementia. The recent study of two cases 
by Facklan (Arch. f. Psychiatrie, 30) confirms the view expressed in former 
editions that the disease is a chronic meningo-encephalitis with atrophy of 
the convolutions. The cord and peripheral nerves he found perfectly 
healthy. The affection is evidently a neuro-degenerative disorder, and has 
no connection with the simple chorea of childhood. 

(e) Rhythmic or Hysterical Chorea. — This is readily recognized by the 
rhythmical character of the movements. It may affect the muscles of the 
abdomen, producing the salaam convulsion, or involve the sterno-mastoid, 
producing a rhythmical movement of the head, or the psoas, or any group 
of muscles. In its orderly rhythm it resembles the canine chorea. 



V. INFANTILE CONVULSIONS {Eclampsia). 

Convulsive seizures similar to those of epilepsy are not infrequent in 
children and in adults. The fit may indeed be identical with epilepsy, 
from which the condition differs in that when the cause is removed there 
is no tendency for the fits to recur. Occasionally, however, the convul- 
sions in children continue and develop into true epilepsy. 

Etiology. — A convulsion in a child may be due to many causes, all 
of which lead to an unstable condition of the nerve-centres, permitting of 
sudden, excessive, and temporary nervous discharges. The following are 
the most important of them: 

(1) Debility, resulting usually from gastro-intestinal disturbance. Con- 
vulsions frequently supervene toward the close of an attack of entero- 
colitis and recur, sometimes proving fatal. Morris J. Lewis has shown 
that the death-rate in children from eclampsia rises steadily with that of 
gastro-intestinal disorders. 

(2) Peripheral irritation. Dentition alone is rarely a cause of convul- 
sions, but is often one of several factors in a feeble, unhealthy infant. 
The greatest mortality from convulsions is during the first six months, be- 
fore the teeth have really cut through the gums. Other irritative causes are 
the overloading of the stomach with indigestible food. It has been sug- 
gested that some of these cases are toxic, owing to the absorption of poi- 
sonous ptomaines. Worms, to which convulsions are so frequently attrib- 
uted, probably have little influence. Among other sources possible are 
phimosis and otitis. 

(3) Rickets. The observation of Sir William Jenner upon the associa- 
tion of rickets and convulsions has been amply confirmed. The spasms 
may be laryngeal, the so-called child-crowing, which, though convulsive in 
nature, can scarcely be reckoned under eclampsia. The influence of this 
condition is more apparent in Europe than in this country, although rickets 
is a common disease, particularly among the colored people. Spasms, local 
or general, in rickets are probably associated with the condition of debility 
and malnutrition and with cranio-tabes. 

(4) Fever. In young children the onset of the infectious diseases is fre- 
quently with convulsions, which often take the place of a chill in the adult. 



1092 



DISEASES OF THE NERVOUS SYSTEM. 



It is not known upon what they depend. Scarlet fever, measles, and pneu- 
monia are most often preceded by convulsions. 

(5) Congestion of the brain. That extreme engorgement of the blood- 
vessels may produce convulsions is shown by their occasional occurrence 
in severe whooping-cough, but their rarity in this disease really indicates 
how small a part mechanical congestion plays in the production of fits. 

(6) Severe convulsions usher in or accompany many of the serious dis- 
eases of the nervous system in children. In more than 50 per cent of the 
cases of infantile hemiplegia the affection follows severe convulsions. They 
less frequently precede a spinal paralysis. They occur with meningitis, 
tuberculous or simple, and with tumors and other lesions of the brain. 

And, lastly, convulsions may occur immediately after birth and persist 
for weeks or months. In such instances there has probably been menin- 
geal haemorrhage or serious injury to the cortex. 

The most important question is the relation of convulsions in children 
to true epilepsy. In Gowers' figures of 1,450 cases of epilepsy, the attacks 
began in 180 during the first three years of life. Of 460 cases of epilepsy 
in children which I have analyzed, in 187 the fits began within the first 
three years. Of the total list the greatest number, 74, was in the first 
year. In nearly all these instances there was no interruption in the con- 
vulsions. That convulsions in early infancy are necessarily followed by 
epilepsy in after life is certainly a mistake. 

Symptoms. — The attack may come on suddenly without any warn- 
ing; more commonly it is preceded by a stage of restlessness, accompanied 
by twitching and perhaps grinding of the teeth. It is rarely so complete 
in its stages as true epilepsy. The spasm begins usually in the hands, most 
commonly in the right hand. The eyes are fixed and staring or are rolled 
up. The body becomes stiff and breathing is suspended for a moment or 
two by tonic spasm of the respiratory muscles, in consequence of which 
the face becomes congested. Clonic convulsions follow, the eyes are rolled 
about, the hands and arms twitch, or are flexed and extended in rhythmical 
movements, the face is contorted, and the head is retracted. The attack 
gradually subsides and the child sleeps or passes into a state of stupor. 
Following indigestion the attack may be single, but in rickets and intestinal 
disorders it is apt to be repeated. Sometimes the attacks follow each other 
with great rapidity, so that the child never rouses but dies in a deep coma. 
If the convulsion has been limited chiefly to one side there may be slight 
paresis after recovery, or in instances in which the convulsions usher in 
infantile hemiplegia, when the child arouses, one side is completely para- 
lyzed. During the fit the temperature is often raised. Death rarely occurs 
from the convulsion itself, except in debilitated children or when the at- 
tacks recur with great frequency. In the so-called hydrocephaloid state in 
connection with protracted diarrhoea convulsions may close the scene. 

Diagnosis. — Coming on when the subject is in full health, the attack 
is probably due either to an overloaded stomach, to some peripheral irrita- 
tion, or occasionally to trauma. Setting in with high fever and vomiting, 
it may indicate the onset of an exanthem, or occasionally be the primary 
symptom of encephalitis, or whatever the condition is which causes infan- 



EPILEPSY. 



1093 



tile hemiplegia. When the attack is associated with debility and with 
rickets the diagnosis is easily made. The carpopedal spasms and pseudo- 
paralytic rigidity which are often associated with rickets, laryngismus stridu- 
lus, and the hydrocephaloid state are usually confined to the hands and 
arms and are intermittent and usually tonic. The convulsions associated 
with tumor or which follow infantile hemiplegia are usually at first Jack- 
sonian in character. After the second year convulsive seizures which come 
on irregularly without apparent cause and recur while the child is appar- 
ently in good health are likely to prove true epilepsy. 

Prognosis. — Convulsions play an important part in infantile mor- 
tality. In Morris J. Lewis's table of deaths in children under ten, 8.5 per 
cent were ascribed to convulsions. West states that 22.35 per cent of deaths 
under one year are caused by convulsions, but this is too high an estimate 
for this country. In chronic diarrhoea convulsions are usually of ill omen. 
Those ushering in fevers are rarely serious, and the same may be said of 
the fits associated with indigestion and peripheral irritation. 

Treatment. — Every source of irritation should be removed. If as- 
sociated with indigestible food, a prompt emetic should be given, followed 
by an enema. The teeth should be examined, and if the gum is swollen, 
hot, and tense, it may be lanced; but never if it looks normal. When 
seen at first, if the paroxysm is severe, no time should be lost by giving 
a hot bath, but chloroform should be given at once, and repeated if neces- 
sary. A child is so readily put under chloroform and with such a small 
quantity that this precedure is quite harmless and saves much valuable 
time. The practice is almost universal of putting the child into a warm 
bath, and if there is fever the head may be douched with cold water. The 
temperature of the bath should not be above 95° or 96°. The very hot 
bath is not suitable, particularly if the fits are due to indigestion. After 
the attack an ice-cap may be placed upon the head. If there is much irri- 
tability, particularly in rickets and in severe diarrhoea, small doses of 
opium will be found efficacious. When the convulsions recur after the 
child comes from under the influence of chloroform it is best to place it 
rapidly under the influence of opium, which may be given as morphia 
hypodermically, in doses of from one twenty-fifth to one thirtieth of a grain 
for a child of one year. Other remedies recommended are chloral by enema, 
in 5-grain doses, and nitrite of amyl. After the attack has passed the 
bromides are useful, of which 5 to 8 grains may be given in a day to a child 
a year old. Eecurring convulsions, particularly if they come on without 
special cause, should receive the most thorough and careful treatment 
with bromides. When associated with rickets the treatment should be 
directed to improving the general condition. 



VI. EPILEPSY. 

Definition. — An affection of the nervous system characterized by at- 
tacks of unconsciousness, with or without convulsions. 

The transient loss of consciousness without convulsive seizures is known 



1094 



DISEASES OF THE NERVOUS SYSTEM. 



as petit mal; the loss of consciousness with general convulsive seizures is 
known as grand mal. Localized convulsions, occurring usually without 
loss of consciousness, are known as epileptiform, or more frequently as 
Jacksonian or cortical epilepsy. 

Etiology. — Age. — In a large proportion of all cases the disease begins 
before puberty. Of the 1,450 cases observed by Gowers, in 422 the disease 
began before the tenth year, and three fourths of the cases began before 
the twentieth year. Of 460 cases of epilepsy in children which I have 
analyzed the age of onset in 427 was as follows: First year, 74; second 
year, 62; third year, 51; fourth year, 24; fifth year, 17; sixth year, 18; 
seventh year, 19; eighth year, 23; ninth year, 17; tenth year, 27; eleventh 
year, 17; twelfth year, 18; thirteenth year, 15; fourteenth year, 21; fif- 
teenth year, 34. Arranged in hemidecades the figures are as follows: From 
the first to the fifth year, 229; from the fifth to the tenth year, 104; from 
the tenth to the fifteenth year, 95. These figures illustrate in a striking 
manner the early onset of the disease in a large proportion of the cases. 
It is well always to be suspicious of epilepsy developing in the adult, for in 
a majority of such cases the convulsions are due to a local lesion. 

Sex. — No special influence appears to be discoverable in this relation, 
certainly not in children. Of 433 cases in my tables, 232 were males and 
203 were females, showing a slight predominance of the male sex. After 
puberty unquestionably, if a large number of cases are taken, the males 
are in excess. The figures of Sieveking and Eeynolds show that the dis- 
ease is rather more prevalent in females than in males. 

Heredity. — Much stress has been laid upon this by many authors as an 
important predisposing cause, and the statistics collected give from 9 to over 
40 per cent. Gowers gives 35 per cent for his cases, which have special 
value apart from other statistics embracing large numbers of epileptics in 
that they were collected by him in his own practice. In our figures it ap- 
pears to play a minor role. In the Infirmary list there were only 31 cases 
in which there was a history of marked neurotic taint, and only 3 in which 
the mother herself had been epileptic. In the Elwyn cases, as might be 
expected, the percentage is larger. Of the 126 there was in 32 a family his- 
tory of nervous derangement of some sort, either paralysis, epilepsy, marked 
hysteria, or insanity. It is interesting to note that in this group, in which 
the question of heredity is carefully looked into, there were only two in 
which the mother had had epilepsy, and not one in which the father had 
been affected. Indeed, I was not a little surprised to find in the list of my 
cases that hereditary influences played so small a part. I have heard this 
opinion expressed by certain French physicians, notably Marie, who in writ- 
ing also upon the question takes strong grounds against heredity as an im- 
portant factor in epilepsy. 

While, then, it may be said that direct inheritance is comparatively un- 
common, yet the children of neurotic families in which neuralgia, insanity, 
and hysteria prevail are more liable to fall victims to the disease. 

Chronic alcoholism in the parents is regarded by many as a potent pre- 
disposing factor in the production of epilepsy. Echeverria has analyzed 
572 cases bearing upon this point and divided them into three classes, of 



EPILEPSY. 



1095 



which 257 eases could be traced directly to alcohol as a cause; 126 cases 
in which there were associated conditions, such as syphilis and traumatism; 
189 cases in which the alcoholism was probably the result of the epilepsy. 
Figures equally strong are given by Martin, who found in 150 insane epi- 
leptics 83 with a marked history of parental intemperance. Of the 126 
Elwyn cases, in which the family history on this point was carefully inves- 
tigated, a definite statement was found in only 4 of the cases. 

Syphilis. — This in the parents is probably less a predisposing than an 
actual cause of epilepsy, which is the direct outcome of local cerebral mani- 
festations. There is no reason for recognizing a special form of syphilitic 
epilepsy. On the other hand, convulsive seizures due to acquired, syphilitic 
disease of the brain are very common. 

Poisons. — Alcohol. — Severe epileptic convulsions may occur in steady 
drinkers. 

Of exciting causes fright is believed to be important, but is less so, I 
think, than is usually stated. Trauma is present in a certain number of 
instances. An important group depends upon a local disease of the brain 
existing from childhood, as seen in the post-hemiplegic epilepsy. Occa- 
sionally cases follow the infectious fevers. Masturbation has been stated 
to be a special cause, but its influence is probably overrated. A large group 
of convulsive seizures allied to epilepsy are due to some toxic agent, as in 
lead poisoning and in uraemia. 

Reflex Causes. — Dentition and worms, the irritation of a cicatrix, some 
local affection, such as adherent prepuce, or a foreign body in the ear or 
the nose, are given as causes. In many of these cases the fits cease after 
the removal of the cause, so that there can be no question of the association 
between the two. In others the attacks persist. Genuine cases of reflex 
epilepsy are, I believe, rare. A remarkable instance of it occurred at the 
Philadelphia Infirmary for Diseases of the Nervous System in the case of 
a man with a testis in the inguinal canal, pressure upon which would cause 
a typical fit. Removal of the organ was followed by cure. 

Cardio-vascular epilepsy is usually a manifestation of advanced arterio- 
sclerosis, and is associated with slow pulse (see Stokes- Adams' Syndrome). 
There may be palpitation and uneasy sensations about the heart prior to 
the attack. The passage of a gall-stone or the removal of pleuritic fluid 
may induce a fit. Indigestion and gastric troubles are extremely common 
in epilepsy, and in many instances the eating of indigestible articles seems 
to precipitate an attack. And lastly, epileptic seizures may occur in old 
people without obvious cause. 

Symptoms.— (1) Grand Mai. — Preceding the fits there is usually a 
localized sensation, known as an aura, in some part of the body. This 
may be somatic, in which the feeling comes from some particular region 
in the periphery, as from the finger or hand, or is a sensation felt in the 
stomach or about the heart. The peripheral sensations preceding the fit 
arc of great value, particularly those in which the aura always occurs in a 
definite region, as in one finger or toe. It is the equivalent of the signal 
symptom in a fit from a brain tumor. The varieties of these sensations 
are numerous. The epigastric sensations arc most common. In these the 



1096 



DISEASES OF THE NERVOUS SYSTEM. 



patient complains of an uneasy sensation in the epigastrium or distress in 
the intestines, or the sensation may not be unlike that of heart-burn and 
may be associated with palpitation. These groups are sometimes known 
as pneumogastric aurae or warnings. 

Of psychical aurae one of the most common, as described by Hughlings 
Jackson, is the vague, dreamy state, a sensation of strangeness or some- 
times of terror. The aurae may be associated with special senses; of these 
the most common are the visual, consisting of flashes of light or sensa- 
tions of color; less commonly, distinct objects are seen. The audi- 
tory aurae consist of noises in the ear, odd sounds, musical tones, or occa- 
sionally voices. Olfactory and gustatory aurae, unpleasant tastes and odors, 
are rare. 

Occasionally the fit may be preceded not by an aura, but by certain 
movements; the patient may turn round rapidly or run with great speed 
for a few minutes, the so-called epilepsia procursiva. In one of the Elwyn 
cases the lad stood on his toes and twirled with extraordinary rapidity, so 
that his features were scarcely recognizable. At the onset of the attack 
the patient may give a loud scream or yell, the so-called epileptic cry. The 
patient drops as if shot, making no effort to guard the fall. In consequence 
of this epileptics frequently injure themselves, cutting the face or head 
or burning themselves. In the attack, as described by Hippocrates, " the 
patient loses his speech and chokes, and foam issues from the mouth, the 
teeth are fixed, the hands are contracted, the eyes distorted, he becomes 
insensible, and in some cases the bowels are affected. And these symptoms 
occur sometimes on the left side, sometimes on the right, and sometimes on 
both." The fit may be described in three stages: 

(a) Tonic Spasm. — The head is drawn back or to the right, and the 
jaws are fixed. The hands are clinched and the legs extended. This tonic 
contraction affects the muscles of the chest, so that respiration is impeded 
and the initial pallor of the face changes to a dusky or livid hue. The 
muscles of the two sides are unequally affected, so that the head and neck 
are rotated or the spine is twisted. The arms are usually flexed at the 
elbows, the hand at the wrist, and the fingers are tightly clinched in the 
palm. This stage lasts only a few seconds, and then the 

(b) Clonic stage begins. The muscular contractions become intermit- 
tent; at first tremulous or vibratory, they gradually become more rapid 
and the limbs are jerked and tossed about violently. The muscles of the 
face are in constant clonic spasm, the eyes roll, the eyelids are opened and 
closed convulsively. The movements of the muscles of the jaw are very 
forcible and strong, and it is at this time that the tongue is apt to be caught 
between the teeth and lacerated. The cyanosis, marked at the end of the 
tonic stage, gradually lessens. A frothy saliva, which may be blood-stained, 
escapes from the mouth. The faeces and urine may be discharged involun- 
tarily. The duration of this stage is variable. It rarely lasts more than 
one or two minutes. The contractions become less violent and the patient 
gradually sinks into the condition of 

(c) Coma. The breathing is noisy or even stertorous, the face con- 
gested, but no longer intensely cyanotic. The limbs are relaxed and the 



EPILEPSY. 



1097 



unconsciousness is profound. After a variable time the patient can be 
aroused, but if left alone he sleeps for some hours and then awakes, com- 
plaining only of slight headache or mental confusion. 

Status Epilepticus. — This is the climax of the disease, in which attacks 
occur in rapid succession, and the patient does not recover consciousness. 
The pulse, respiration, and temperature rise in the attack. It is a serious 
condition, and often proves fatal. 

After the attack the reflexes are sometimes absent; more frequently they 
are increased and the ankle clonus can usually be obtained. The state of 
the urine is variable, particularly as regards the solids. The quantity 
is usually increased after the attack, and albumin is not infrequently 
present. 

Post-epileptic symptoms are of great importance. The patient may be 
in a trance-like condition, in which he performs actions of which subse- 
quently he has no recollection. More serious are the attacks of mania^ in 
which the patient is often dangerous and sometimes homicidal. It is held 
by good authorities that an outbreak of mania may be substituted for the 
fit. And, lastly, the mental condition of an epileptic patient is often seri- 
ously impaired, and profound defects are common. 

Paralysis, which rarely follows the epileptic fit, is usually hemiplegic 
and transient. 

Slight disturbances of speech also may occur; in some instances forms 
of sensory aphasia. 

The attacks may occur at night, and a person may be epileptic for years 
without knowing it. As Trousseau truly remarks, when a person tells us 
that in the night he has incontinence of urine and awakes in the morning 
with headache and mental confusion, and complains of difficulty in speech 
owing to the fact that he has bitten his tongue; if, also, there are on the 
skin of the face and neck purpuric spots, the probability is very strong in- 
deed that he is subject to nocturnal epilepsy. 

(2) Petit Mai. — This is epilepsy without the convulsions. The attack 
consists of transient unconsciousness, which may come on at any time, ac- 
companied or unaccompanied by a feeling of faintness and vertigo. Sud- 
denly, for example, at the dinner table, the subject stops talking and eating, 
the eyes become fixed, and the face slightly pale. Anything which may 
have been in the hand is usually dropped. In a moment or two conscious- 
ness is regained and the patient resumes conversation as if nothing had 
happened. In other instances there is slight incoherency or the patient 
performs some almost automatic action. He may begin to undress himself 
and on returning to consciousness find that he has partially disrobed. He 
may rub his beard or face, or may spit about in a careless way. In other 
attacks the patient may fall without convulsive seizures. A definite aura 
is rare. Though transient, unconsciousness and giddiness are the most 
constant manifestations of petit mat; there are many other equivalent mani- 
festations, such as sudden jerkings in the limbs, sudden tremor, or a sudden 
visual sensation. Gowers mentions no less than seventeen different mani- 
festations of petit mat. Occasionally there are eases in which the patient 



1098 



DISEASES OF THE NERVOUS SYSTEM. 



has a sensation of losing his breath and may even get red in the face. I 
have seen such attacks also in children. 

After the attack the patient may be dazed for a few seconds and per- 
form certain automatic actions, which may seem to be volitional. As men- 
tioned, undressing is a common action, but all sorts of odd actions may be 
performed, some of which are awkward or even serious. One of my pa- 
tients after an attack was in the habit of tearing anything he could lay 
hands on, particularly books. Violent actions have been committed and 
assaults made, frequently giving rise to questions which come before the 
courts. This condition has been termed masked epilepsy, or epilepsia 
larvata. 

In a majority of the cases of petit mat convulsions finally occur, at first 
slight, but ultimately the grand mat becomes well developed, and the attacks 
may then alternate. 

(3) Jacksoniail Epilepsy. — This is also known as cortical, symptomatic, 
or partial epilepsy. It is distinguished from the ordinary epilepsy by the 
important fact that consciousness is retained or is lost late. The attacks 
are usually the result of irritative lesions in the motor zone, though there 
are probably also sensory equivalents of this motor form. In a typical 
attack the spasm begins in a limited muscle group of the face, arm, or leg. 
The zygomatic muscles, for instance, or the thumb may twitch, or the toes 
may first be moved. Prior to the twitching the patient may feel a sensation 
of numbness or tingling in the part affected. The spasm extends and may 
involve the muscles of one limb only or of the face. The patient is con- 
scious throughout and watches, often with interest, the march of the spasm. 

The onset may be slow, and there may be time, as in a case which I 
have reported, for the patient to place a pillow on the floor, so as to be 
as comfortable as possible during the attack. The spasms may be local- 
ized for years, but there is a great risk that the partial epilepsy may become 
general. The condition is due, as a rule, to an irritative lesion in the motor 
zone. Thus of 107 cases analyzed by Koland, there were 48 of tumor, 21 
instances of inflammatory softening, 14 instances of acute and chronic 
meningitis, and 8 cases of trauma. The remaining instances were due to 
haemorrhage or abscess, or were associated with sclerosis cerebri. Two 
other conditions may be mentioned, which may cause typical Jacksonian 
epilepsy — namely, uraemia and progressive paralysis of the insane. A con- 
siderable number of the cases of Jacksonian epilepsy are found in children 
following hemiplegia, the so-called post-hemiplegic epilepsy. The con- 
vulsions usually begin on the affected side, either in the arm or leg, and the 
fit may be unilateral and without loss of consciousness. Ultimately they 
become more severe and general. 

Diagnosis. — In major epilepsy the suddenness of the attack, the 
abrupt loss of consciousness, the order of the tonic and clonic spasm, and 
the relaxation of the sphincters at the height of the attack are distinctive 
features. The convulsive seizures due to uraemia are epileptic in character 
and usually readily recognized by the existence of greatly increased ten- 
sion and the condition of the urine. Practically in young adults hysteria 
causes the greatest difficulty, and may closely simulate true epilepsy. The 



EPILEPSY. 1099 

following table from Gowers' work draws clearly the chief differences be- 
tween them: 





Epileptic. 


Hysteroid. 




none. 


emotion. 




any, but especially unilateral 


palpitation, malaise, choking, bi- 




or epigastric auras. 


lateral foot aura. 




always sudden. 


often gradual. 




at onset. 


during course. 




rigidity followed by "jerk- 


rigidity or " struggling," throwing 




ing," rarely rigidity alone. 


about of limbs or head, arching 






of back. 




tongue. 


lips, hands, or other people and 






things. 




frequent. 


never. 




occasional. 


never. 


Talking 


never. 


frequent. 




a few minutes. 


more than ten minutes, often much 






longer. 


Restraint necessary. . . 


to prevent accident. 


to control violence. 




spontaneous. 


spontaneous or induced (water, 






etc.). 



Eecurring epileptic seizures in a person over thirty who has not had 
previous attacks is always suggestive of organic disease. According to H. 
C. Wood, whose opinion is supported by that of Fournier, in 9 cases out of 
10 the condition is due to syphilis. 

Petit mat must be distinguished from attacks of syncope, and the ver- 
tigo of Meniere's disease, of a cardiac lesion, and of indigestion. In these 
cases there is no actual loss of consciousness, which forms a characteristic 
though not an invariable feature of petit mat. 

Jacksonian epilepsy has features so distinctive and peculiar that it is 
at once recognized. It is by no means easy, however, always to determine 
upon what the spasm depends. Irritation in the motor centres may be due 
to a great variety of causes, among which tumors and localized meningo- 
encephalitis are the most frequent; but it must not be forgotten that in 
uraemia localized epilepsy may occur. The most typical Jacksonian spasms 
also are not infrequent in general paresis of the insane. 

Prognosis. — This may be given to-day in the words of Hippocrates: 
" The prognosis in epilepsy is unfavorable when the disease is congenital, 
and when it endures to manhood, and when it occurs in a grown person 
without any previous cause. . . . The cure may be attempted in young 
persons, but not in old." 

Death during the fit rarely occurs, but it may happen if the patient 
falls into the water or if the fit comes on while he is eating. Occasionally 
the fits seem to stop spontaneously. Tin's is particularly the case in the 
epilepsy in children which has followed the convulsions of teething or of 
the fevers. Frequency of the attacks and marked mental disturbance are 
unfavorable indications. Hereditary predisposition is apparently of no 
moment in the prognosis. The outlook is better in males than in females. 
The post-hemiplegic epilepsy is rarely arrested. Of the cases coming on 



1100 



DISEASES OF THE NERVOUS SYSTEM. 



in adults, those due to syphilis and to local affections of the brain allow a 
more favorable prognosis. 

Treatment. — General. — In the case of children the parents should 
be made to understand from the outset that epilepsy in the great majority of 
cases is an incurable affection, so that the disease may interfere as little as 
possible with the education of the child. The subjects need firm but kind 
treatment. Indulgence and yielding to caprices and whims are followed 
by weakening of the moral control, which is so necessary in these cases. 
The disease does not incapacitate a person for all occupation. It is much 
better for epileptics to have some definite pursuit. There are many in- 
stances in which they have been persons of extraordinary mental and bodily 
vigor, as, for example, Julius Csesar and Napoleon. One of the most dis- 
tressing features in epilepsy is the gradual mental impairment which fol- 
lows in a certain number of cases. If such patients become extremely irri- 
table or show signs of violence they should be placed under supervision in 
an asylum. Marriage should be forbidden to epileptics. During the attack 
a cork or bit of rubber should be placed between the teeth and the clothes 
should be loosened. The patient should be in the recumbent posture. As 
the attack usually passes off with rapidity, no special treatment is necessary, 
but in cases in which the convulsion is prolonged a few whiffs of chloro- 
form or nitrite of amyl or a hypodermic of a quarter of a grain of morphia 
may be given. 

Dietetic. — The old authors laid great stress upon regimen in epilepsy. 
The important point is to give the patient a light diet at fixed hours, and 
on no account to permit overloading of the stomach. Meat should not be 
given more than once a day. There are cases in which animal food seems 
injurious. A strict vegetable diet has been warmly recommended. The 
patient should not go to sleep until the completion of gastric digestion. 

Medicinal. — The bromides are the only remedies which have a special 
influence upon the disease. Either the sodium or potassium salt may be 
given. Sodium bromide is probably less irritating and is better borne for 
a long period. It may be given in milk, in which it is scarcely tasted. In 
all instances the dilution should be considerable. In adults it is well taken 
in soda water or in some mineral water. The dose for an adult should be 
from half a drachm to a drachm and a half daily. As Seguin recommends, 
it is often best to give but a single dose daily, about four to six hours before 
the attacks are most likely to occur. For instance, in the case of nocturnal 
epilepsy a drachm should be given an hour or two after the evening meal. 
If the attack occurs early in the morning, the patient should take a full 
dose when he awakes. When given three times a day it is less disturbing 
after meals. Each case should be careiKillv studied to determine how much 
bromide should be used. The individual susceptibility varies and some 
patients require more than others. Fortunately, children take the drug 
well and stand proportionately larger doses than adults. Saturation is 
indicated by certain unpleasant effects, particularly drowsiness, mental 
torpor, and gastric and cardiac distress. Loss of palate reflex is one of the 
earliest indications that the system is under the influence of the bromides, 
and is a condition which should be attained. A very unpleasant feature 



EPILEPSY. 



1104 



is the development of acne, which, however, is no indication of bromism. 
Segnin states that the tendency to this is much diminished by giving the 
drug largely diluted in alkaline waters and administering from time to time 
full doses of arsenic. To be effectual the treatment should be continued 
for a prolonged period and the cases should be incessantly watched in order 
to prevent bromism. The medicine should be continued for at least two 
years after the cessation of the fits; indeed, Segnin recommends that the 
reduction of the bromides should not be begun until the patient has been 
three years without any manifestations. Written directions should be given 
to the mother or to the friends of the patient, and he should not himself 
be held, responsible for the administration of the medicine. A book should 
be provided in which the daily number of attacks and the amount of medi- 
cine taken should be noted. The addition of belladonna to the bromide is 
warmly recommended by Black, of Glasgow. In very obstinate cases Flech- 
sig uses opium, 5 or 6 grains, in three doses daily; then at the end of six 
weeks opium is stopped and the bromides in large amounts, 75 to 100 grains 
daily, are used for two months. 

Among other remedies which have been recommended as controlling 
epilepsy are chloral, cannabis indica, zinc, nitroglycerin, and borax. Nitro- 
glycerin is sometimes advantageous in petit mal, but is not of much service 
in the major form. To be beneficial it must be given in full doses, from 2 
to 5 minims of the 1-per-cent solution, and increased until the physiological 
effects are produced. Counter-irritation is rarely advisable. When the 
aura is very definite and constant in its onset, as from the hand or from the 
toe, a blister about the part or a ligature tightly applied may stop the on- 
coming fit. In children, care should be taken that there is no source of 
peripheral irritation. In boys, adherent prepuce may occasionally be the 
cause. The irritation of teething, the presence of worms, and foreign bodies 
in the ears or nose have been associated with epileptic seizures. 

The subjects of a chronic and, in most cases, a hopelessly incurable 
disease, epileptic patients form no small portion of the unfortunate victims 
of charlatans and quacks, who prescribe to-day, as in the time of the father 
of medicine, "purifications and spells and other illiberal practices of like 
kind." 

Surgical. — In Jacksonian epilepsy the propriety of surgical interfer- 
ence is universally granted. It is questionable, however, whether in the 
epilepsy following hemiplegia, considering the anatomical condition, it is 
likely to be of any benefit. In idiopathic epilepsy, when the fit starts in 
a certain region — the thumb, for instance — and the signal symptom is in- 
variable, the centre controlling this part may be removed. This procedure 
has been practised by Macewen, Horsley, Keen, and others, but time alone 
can determine its value. The traumatic epilepsy, in which the fit follows 
fracture, is much more hopeful. 

The operation, per se, appears in some cases to have a curative effect. 
Thus of 50 cases of trephining for epilepsy in which nothing abnormal was 
found to account for the symptoms, 25 were reported as cured and 18 as im- 
proved. The operations have not been always on the skull, and White 
has collected an interesting scries in which various surgical procedures have 



1102 



DISEASES OF THE NERVOUS SYSTEM. 



been resorted to, often with curative effect, such as ligation of the carotid 
artery, castration, tracheotomy, excision of the superior cervical ganglia, 
incision of the scalp, circumcision, etc. 



VII. MIGRAINE (Hemicrania; Sick Headache). 

Definition. — A paroxysmal affection characterized by severe headache, 
usually unilateral, and often associated with disorders of vision. 

Etiology. — The disease is frequently hereditary and has occurred 
through several generations. Women and the members of neurotic fami- 
lies are most frequently attacked. It is an affection from which many dis- 
tinguished men have suffered and have left on record an account of the dis- 
ease, notably the astronomer Airy. Edward Liveing's work is the standard 
authority upon which most of the subsequent articles have been based. A 
gouty or rheumatic taint is present in many instances. Sinkler has called 
special attention to the frequency of reflex causes. Migraine has long been 
known to be associated with uterine and menstrual disorders. Nutritive 
disturbances are common, and attempts have been made by Haig and others 
to associate the attacks with disturbed uric-acid output. Certainly the 
amount of uric acid excreted just prior to and during an attack is reduced. 
Others regard the disease as a toxaemia from disordered intestinal digestion. 
Many of the headaches from eye-strain are of the hemicranial type. Brun- 
ton refers to caries of the teeth as a cause of these headaches, even when 
not associated with toothache. Cases have been described in connection 
with adenoid growths in the pharynx, and particularly with abnormal con- 
ditions of the nose. Many of the attacks of severe headaches in children are 
of this nature, and the eyes and nostrils should be examined with great 
care. Sinkler refers to a case in a child of two years, and Gowers states that 
a third of all the cases begin between the fifth and tenth years of age. The 
direct influences inducing the attack are very varied. Powerful emotions 
of all sorts are the most potent. Mental or bodily fatigue, digestive dis- 
turbances, or the eating of some particular article of food may be followed 
by the headache. The paroxysmal character is one of the most striking 
features, and the attacks may recur on the same day every week, every fort- 
night, or every month. Headaches of the migraine type may recur for 
years in connection with chronic Bright's disease. 

Symptoms. — Premonitory signs are present in many cases, and the 
patient can tell when an attack is coming on. Remarkable prodromata 
have been described, particularly in connection with vision. Apparitions 
may appear — visions of animals, such as mice, dogs, etc. Transient hemi- 
anopia or scotoma may be present. In other instances there is spasmodic 
action of the pupil on the affected side, which dilates and contracts alter- 
nately, the condition known as liippus. Frequently the disturbance of 
vision is only a blurring, or there are balls of light, or zigzag lines, or the 
so-called fortification spectra (teichopsia), which may be illuminated with 
gorgeous colors. Disturbances of the other senses are rare. Numbness of 
the tongue and face and occasionally of the hand may occur with tingling. 



MIGRAINE. 



1103 



More rarely there are cramps or spasms in the muscles of the affected side. 
Transient aphasia has also been noted. Some patients show marked psy- 
chical disturbance, either excitement or, more commonly, mental confusion 
or great depression. Dizziness occurs in some cases. The headache follows 
a short time after the prodromal symptoms have appeared. It is cumulative 
and expansile in character, beginning as a localized small spot, which is 
generally constant either on the temple or forehead or in the eyeball. It 
is usually described as of a penetrating, sharp, boring character. At first 
unilateral, it gradually spreads and involves the side of the head, sometimes 
the neck, and the pains may pass into the arm. In other cases both sides 
are affected. Nausea and vomiting are common symptoms. If the attack 
comes on when the stomach is full, vomiting usually gives relief. Vaso- 
motor symptoms may be present. The face, for instance, may be pale, and 
there may be a marked difference between the two sides. Subsequently the 
face and ear on the affected side may become a burning red from the vaso- 
dilator influences. The pulse may be slow. The temporal artery on the 
affected side may be firm and hard, and in a condition of arterio-sclerosis — 
a fact which has been confirmed anatomically by Thoma. Few affections 
are more prostrating than migraine, and during the paroxysm the patient 
may scarcely be able to raise the head from the pillow. The slightest noise 
or light aggravates the condition. 

The duration of the entire attack is variable. The severer forms usually 
incapacitate the person for at least three days. In other instances the en- 
tire attack is over in a day. The disease recurs for years, and in cases with 
a marked hereditary tendency may persist throughout life. In women the 
attacks often cease after the climateric, and in men after the age of fifty. 
Two of the greatest sufferers I have known, who had recurring attacks 
every few weeks from early boyhood, now have complete freedom. 

The nature of the disease is unknown. Liveing's view, that it is a 
nerve storm or form of periodic discharge from certain sensory centres and 
is related to epilepsy, has found much favor. According to this view, it 
is the sensory equivalent of a true epileptic attack. Mollendorf, Latham, 
and others regard it as a vaso-motor neurosis, and hold that the early symp- 
toms are due to vaso-constrictor and the later symptoms to vaso-dilator 
influences. The fact of the development of arterio-sclerosis in the arteries 
of the affected side is a point of interest bearing upon this view. 

Treatment. — The patient is fully aware of the causes which precipi- 
tate an attack. Avoidance of excitement, regularity in the meals, and 
moderation in diet are important rules. I have known cases greatly bene- 
fitted by a strict vegetable diet. The treatment should be directed toward 
the removal of the conditions upon which the attacks depend. In children 
much may be done by watchfulness and care on the part of the mother in 
regulating the bowels and watching the diet of the child. Errors of re- 
fraction should be adjusted. On no account should such children be allowed 
to compete in school for prizes. A prolonged course of bromidea sometimes 
proves successful. If anamiia is present, iron and arsenic should be given. 
When the arterial tension is increased a course of nitroglycerin may he 
tried. Not too much, however, should be expected of the preventive treat- 



1104 



DISEASES OF THE NERVOUS SYSTEM. 



nient of migraine. It must be confessed that in a very large proportion of 
the cases the headaches recur in spite of all we can do. Herter advises, so 
soon as the patient has any intimation of the attack, to wash out the stom- 
ach with water at 105°, and to give a brisk saline cathartic. During the 
paroxysm the patient should be kept in bed and absolutely quiet. If the 
patient feels faint and nauseated, a small cup of hot, strong coffee or 20 
drops of chloroform give relief. Cannabis indica is probably the most satis- 
factory remedy. Seguin recommends a prolonged course of the drug. 
Antip}-rin, antif ebrin, and phenacetin have been much used of late. When 
given early, at the very outset of the paroxysm, they are sometimes effect- 
ive. Smaller, repeated doses are more satisfactory. Of other remedies, 
caffeine, in 5-grain doses of the citrate, nux vomica, and ergot have been 
recommended. Electricity does not appear to be of much service. And 
lastly, in obstinate cases, an ordinary tape seton may be inserted through 
the skin at the back of the neck, to be worn for three months, a plan of 
treatment which has the strongest possible recommendation from Mr. 
Whitehead, of Manchester. 

VIII. NEURALGIA. 

Definition. — A painful affection of the nerves, due either to functional 
disturbance of their central or peripheral extremities or to neuritis in their 
course. 

Etiology. — Members of neuropathic families are most subject to the 
disease. It affects women more than men. Children are rarely attacked. 
Of all causes, debility is the most frequent. It is often the first indication 
of an enfeebled nervous system. The various forms of ansemia are fre- 
quently associated with neuralgia. It may be a prominent feature at the 
onset of certain acute diseases, particularly typhoid fever. Malaria is be- 
lieved to be a potent cause, but it has not been shown that neuralgia is 
more frequent in malarial districts, and the error has probably arisen from 
regarding periodicity as a special manifestation of paludism. It occasion- 
ally occurs in malarial cachexia. Exposure to cold is a cause in very sus- 
ceptible persons. Eeflex irritation, particularly from carious teeth, may 
induce neuralgia of the fifth nerve. The disease occurs sometimes in rheu- 
matism, gout, lead poisoning, and diabetes. Persistent neuralgia may be 
a feature of latent Bright's disease. 

Symptoms. — Before the onset of the pain there may be uneasy sen- 
sations, sometimes tingling in the part which will be affected. The pain 
is localized to a certain group or division of nerves, usually affecting one 
side. The pain is not constant, but paroxysmal, and is described as stab- 
bing, burning, or darting in character. The skin may be exquisitely ten- 
der in the affected region, particularly over certain points along the course 
of the nerve, the so-called tender points. Movements, as a rule, are pain- 
ful. Trophic and vaso-motor changes may accompany the paroxysm; the 
skin may be cool, and subsequently hot and burning; occasionally local 
oedema or erythema occurs. More remarkable still are the changes in the 
hair, which may become blanched (canities), or even fall out. Fortunately, 



NEURALGIA. 



1105 



such alterations are rare. Twitchings of the muscles, or even spasms, 
may be present during the paroxysm. After lasting a variable time — from 
a few minutes to many hours — the attack subsides. Eecurrence may be 
at definite intervals — every day at the same hour, or at intervals of two, 
three, or even seven days. Occasionally the paroxysms develop only at the 
catamenia. This periodicity is quite as marked in non-malarial as in ma- 
larial regions. 

Clinical Varieties, depending on the Nerve Groups affected— (1) Tri- 
facial Neuralgia; Tic Douloureux; Prosopalgia. — All the branches are 
rarely involved together. The ophthalmic is most often affected, but in 
severe attacks the pains, though more intense in one division, radiate over 
the other branches. At the outset there may be hyperesthesia of the skin 
and sensitiveness of the mucous membrane. Pressure is painful at the points 
of emergence of the nerve trunk, and where the nerves enter the muscles. 
Sometimes in addition, as Trousseau pointed out, there are pains at the 
occipital protuberance and in the upper cervical spines. When the oph- 
thalmic division is affected the eye may weep and the conjunctivae are in- 
jected and painful. In the upper maxillary division there is a tender point 
where the nerve leaves the infraorbital canal, and the pain is specially 
marked along the upper teeth. In the lower branches, which are more 
frequently involved, there are painful points along the auriculo-temporal 
nerve and the pain radiates in the region of the ear along the lower jaw 
and teeth. The movements of mastication and speaking may be painful. 
Salivation is not uncommon. Herpes may occur about the eye or the lips. 
In protracted cases there may be atrophy or induration of the skin. Some 
of the forms of facial neuralgia are of frightful intensity and the recurring 
attacks render the patient's life almost insupportable. 

(2) C ervico-occipital neuralgia involves the posterior branches of the 
first four cervical nerves, particularly the inferior occipital, at the emer- 
gence of which there is a painful point about half-way between the mastoid 
process and the first cervical vertebra. It may be caused by cold, and these 
nerves are often affected in cervical caries. 

(3) Cervico-brachial neuralgia involves the sensory nerves of the brachial 
plexus, particularly in the cubital division. When the circumflex nerve is • 
involved the pain is in the deltoid. The pain is most commonly about the 
shoulder and down the course of the ulnar nerve. There is usually a 
marked tender point upon this nerve at the elbow. This form rarely fol- 
lows cold, but more frequently results from rheumatic affections of the 
joints, and trauma. 

(4) Neuralgia of the phrenic nerve is rare. It is sometimes found in 
pleurisy and in pericarditis. The pain is chiefly at the lower part of the 
thorax on a line with the insertion of the diaphragm, and here may be 
painful points on deep pressure. Full inspiration is painful, and there is 
great sensitiveness on coughing or in the performance of any movement by 
which the diaphragm is suddenly depressed. 

(.5) Intercostal Neuralgia. — Next to the tic douloureux this is the most 
important form. It is most frequent in women and very common in hys- 
teria. The pain in caries and aneurism is fell in the intercostal nerves. 
69 



1106 



DISEASES OF THE NERVOUS SYSTEM. 



Herpes Zoster (Acute Hcemorrhagic Inflammation of the Posterior 

Ganglia). 

The researches of Head and Campbell make it very probable that herpes 
zoster is an acute specific disease of the nervous system, with a localization 
in the ganglia of the posterior roots. There is often a prodromal period, 
in which the patient feels ill, has pain, and the rash comes out on the 
third or fourth day. It often has a seasonal prevalence. The changes in 
the posterior root ganglion resemble very closely those of the gray matter 
of the ventral horn in anterior poliomyelitis. There are haemorrhages and 
inflammatory foci, with destruction of certain of the ganglion-cells. A 
single ganglion is usually affected, more commonly those which receive 
afferent impulses from the viscera. A degeneration occurs in those fibres 
entering the spinal cord from the nerve, and which run up into the pos- 
terior column. The pain of zona may persist indefinitely, and it has been 
known to be so intractable that in despair the person has committed suicide. 

(6) Lumbar Neuralgia. — The affected nerves are the posterior fibres of 
the lumbar plexus, particularly the ilio-scrotal branch. The pain is in 
the region of the iliac crest, along the inguinal canal, in the spermatic 
cord, and in the scrotum or labium ma jus. The affection known as irritable 
testis, probably a neuralgia of this nerve, may be very severe and accom- 
panied by syncopal sensations. 

(7) Coccydynia. — This is regarded as a neuralgia of the coccygeal plexus. 
It is most common in women, and is aggravated by the sitting posture. It 
is very intractable, and may necessitate the removal of the coccyx, an opera- 
tion, however, which is not always successful. Neuralgias of the nerves 
-of the leg have already been considered. 

(8) Neuralgias of the Nerves of the Feet. 

Painful Heel. — Both in women and men there may be about the heel 
severe pains which interfere seriously with walking — the pododynia of S. 
D. Gross. There may be little or no swelling, no discoloration, and no 
affection of the joints. 

Plantar Neuralgia. — This is often associated with a definite neuritis, 
such as follows typhoid fever, and has been seen in an aggravated form 
in caisson disease (Hughes). The pain may be limited to the tips of the 
toes or to the ball of the great toe. Numbness, tingling, and hyperesthesia 
or sweating may occur with it. Following the cold-bath treatment in ty- 
phoid fever it is not uncommon for patients to complain of great sensi- 
tiveness in the toes. 

Metatarsalgia. — Morton's (Thomas G.) " painful affection of the fourth 
metatarso-phalangeal articulation " is a peculiar and very trying disorder, 
seen most frequently in women, and usually in one foot. Morton regards 
it as due to a pinching of the metatarsal nerve. The disease rarely gets well 
without operation. The red, painful neuralgia — erythromelalgia — is de- 
scribed under the vaso-motor and trophic disturbances. 

(9) Visceral Neuralgias. — The more important of these have already 
been referred to in connection with the cardiac and the gastric neuroses. 
They are most frequent in women, and are constant accompaniments of 
neurasthenia and hysteria. The pains are most common in the pelvic 
region, particularly about the ovaries. Nephralgia is of great interest, for, 



PROFESSIONAL SPASMS; OCCUPATION NEUROSES. HOT 



as has already been mentioned, the symptoms may closely simulate those 
of stone. 

Treatment. — Causes of reflex irritation should be carefully removed. 
The neuralgia, as a rule, recurs unless the general health improves; so that 
tonic and hygienic measures of all sorts should be employed. Often a 
change of air or surroundings will relieve a severe neuralgia. I have 
known obstinate cases to be cured by a prolonged residence in the moun- 
tains, with an out-of-door life and plenty of exercise. A strict vegetable 
diet will sometimes relieve the neuralgia or headache of a gouty person. Of 
general remedies, iron is often a specific in the cases associated with chloro- 
sis and anaemia. Arsenic, too, is very beneficial in these forms, and should 
be given in ascending doses. The value of quinine has been much over- 
rated. It probably has no more influence than any other bitter tonic, ex- 
cept in the rare instances in which the neuralgia is definitely associated with 
malarial poisoning. Strychnine, cod-liver oil, and phosphorus are also ad- 
vantageous. Of remedies for the pain, the new analgesics should first be 
tried — antipyrin, antifebrin, and phenacetin — for they are sometimes of 
service. Morphia should be given with great caution, and only after other 
remedies have been tried in vain. On no consideration should the patient 
be allowed to use the hypodermic syringe. Gelsemium is highly recom- 
mended. Of nervine stimulants, valerian and ether, which often act well 
together, may be given. Alcohol is a valuable though dangerous remedy, 
and should not be ordered for women. In the trifacial neuralgia nitro- 
glycerin in large doses may be tried. Aconitia in doses of from one two- 
hundredth to one one-hundred-and-fiftieth of a grain may be tried. In 
gouty and rheumatic subjects cannabis indica and cimicifuga are recom- 
mended with the lithium salts. 

Of local applications, the thermo-cautery is invaluable, particularly in 
zona and the more chronic forms of neuralgia. Acupuncture may be used, 
or aquapuncture, the injection of distilled water beneath the skin. Chloro- 
form liniment, camphor and chloral, menthol, the oleates of morphia, atro- 
pia, and belladonna used with lanolin may be tried. Freezing over the 
tender point with ether spray is sometimes successful. The continuous 
current may be used. The sponges should be warm, and the positive pole 
should be. placed near the seat of the pain. The strength of the current 
should be such as to cause a slight tingling or burning, but not pain. 

The surgical treatment of intractable neuralgia embraces nerve stretch- 
ing and excision. The latter is the more satisfactory, but too often the 
pain returns. 

IX. PROFESSIONAL SPASMS; OCCUPATION NEUROSES. 

The continuous and excessive use of the muscles in performing a cer- 
tain movement may be followed by an irregular, involuntary spasm or 
cramp, which may completely check the performance of the action. The 
condition is found most frequently in writers, hence the term writer's cramp 
or scrivener's palsy; but it is also common in piano and violin players and 



1108 



DISEASES OF THE NERVOUS SYSTEM. 



in telegraph operators. The spasms occur in many other persons, such as 
milkmaids, weavers, and cigarette-rollers. 

The most common form is writer^ cramp, which is much more fre- 
quent in men than in women. Of 75 cases of impaired writing power re- 
ported by Poore, all of the instances of undoubted writer's cramp were in 
men. Morris J. Lewis states that in this country, in the telegrapher's 
cramp, women, who are employed a great deal in telegraphy, are much 
less frequently affected (only 4 out of 43 cases). Persons of a nervous 
temperament are more liable to the disease. Occasionally it follows slight 
injury. 

Gowers states that in a majority of the cases a faulty method of writing 
has been employed, using either the little finger or the wrist as the fixed 
point. Persons who write from the middle of the forearm or from the elbow 
are rarely affected. 

No anatomical changes have been found. The most reasonable ex- 
planation of the disease is that it results from a deranged action of the 
nerve centres presiding over the muscular movements involved in the act 
of writing, a condition which has been termed irritable weakness. " The 
education of centres which may be widely separated from each other for the 
performance of any delicate movement is mainly accomplished by lessen- 
ing the lines of resistance between them, so that the movement, which was 
at first produced by a considerable mental effort, is at last executed almost 
unconsciously. If, therefore, through prolonged excitation, this lessened 
resistance be carried -too far, there 'is an increase and irregular discharge 
of nerve energy, which gives rise to spasm and disordered movemeut. Ac- 
cording to this view, the muscular weakness is explained by an impairment of 
nutrition accompanying that of function, and the diminished faradic excita- 
bility by the nutritional disturbance descending the motor nerves " .(Cray)- 

Symptoms. — These may be described under five heads (Lewis). 

(a) Cramp or Spasm. — This is often an early symptom and most com- 
monly affects the forefinger and thumb; or there may be a combined move- 
ment of flexion and adduction of the thumb, so that the pen may be twisted 
from the grasp and thrown to some distance. Weir Mitchell has described 
a lock-spasm, in which the fingers become so firmly contracted upon the 
pen that it cannot be removed. 

(b) Paresis and Paralysis. — This may occur with the spasm or alone. 
The patient feels a sense of weakness and debility in the muscles of the 
hand and arm and holds the pen feebly. Yet in these circumstances the 
grasp of the hand may be strong and there may be no paralysis for ordinary 
acts. 

(c) Tremor. — This is most commonly seen in the forefinger and may 
be a premonitory symptom of atrophy. It is not an important symptom, 
and is rarely sufficient to produce disability. 

(d) Pain. — Abnormal sensations, particularly a tired feeling in the 
muscles, are very constantly present. Actual pain is rare, but there may 
be irregular shooting pains in the arm. Numbness or soreness may exist. 
If, as sometimes happens, a subacute neuritis develops, there may be pain 
over the nerves and numbness or tingling in the fingers. 



TETANY. 



1109 



(e) Vaso-motor Disturbances. — These may occur in severe cases. There 
may be hyperesthesia. Occasionally the skin becomes glossy, or there is 
a condition of local asphyxia resembling chilblains. In attempting to 
write, the hand and arm may become flushed and hot and the veins in- 
creased in size. Early in the disease the electrical reactions are normal, but 
in advanced cases there may be diminution of faradic and sometimes in- 
crease in the galvanic irritability. 

Diagnosis. — A well-marked case of writer's cramp or palsy could 
scarcely be mistaken for any other affection. Care must be taken to ex- 
clude the existence of any cerebro-spinal disease, such as progressive mus- 
cular atrophy or hemiplegia. The physician is sometimes consulted by 
nervous persons who fancy they are becoming subject to the disease and 
complain of stiffness or weakness without displaying any characteristic 
features. 

Prognosis. — The course of the disease is usually chronic. If taken 
in time and if the hand is allowed perfect rest, the condition may im- 
prove rapidly, but too often there is a strong tendency to recurrence. The 
patient may learn to write with the left hand, but this also may after a 
time be attacked. 

Treatment. — Various prophylactic measures have been advised. As 
mentioned, it is important that a proper method of writing be adopted. 
Gowers suggests that if all persons wrote from the shoulder writers cramp 
would practically not occur. Various devices have been invented for re- 
lieving the fatigue, but none of them are very satisfactory. The use of the 
type-writer has diminished very much the frequency of scrivener's palsy. 
Eest is essential. ~No measures are of value without this. Massage and 
manipulation, when combined with systematic gymnastics, give the best 
results. Poore recommends the galvanic current applied to the muscles, 
which are at the same time rhythmically exercised. In very obstinate cases 
the condition remains incurable. I saw a few years ago a distinguished 
gynaecologist who had had writer's cramp twenty years before, and who had 
all sorts of treatment, including the Wolff's method, without any avail. 
He still has it in aggravated form, but he can do all the finer manipulations 
of operative work without any difficulty. 

The nutrition of the patients is apt to be much impaired, and cod-liver 
oil, strychnia, and other tonics will be found advantageous. Local appli- 
cations are of little benefit. Tenotomy and nerve-stretching have been 
abandoned. 

X. TETANY. 

Definition. — An affection characterized by peculiar bilateral tonic 
spasms, either paroxysmal or continued, of the extremities. 

Etiology. — The disease occurs under very different conditions, of 
which the following may be recognized: 

(a) Epidemic tetany, also known as rheumatic tetany. In certain 
parts of the continent of Europe the disease has prevailed widely, particu- 
larly in the winter season. Von Jaksch, who has described an epidemic 



1110 



DISEASES OF THE NERVOUS SYSTEM. 



form occurring in young men of the working classes, sometimes with slight 
fever, regards the disease as infectious. This form is acute, lasting only 
two or three weeks and rarely proving fatal. 

(&) A majority of the cases are found in association with debility fol- 
lowing lactation and chronic diarrhoea, or in the malnutrition of rickets. 
From its occurrence in nursing women Trousseau called it nurse's con- 
tracture. It may also develop during pregnancy or recur in successive 
pregnancies. It has been found as a sequence of the acute fevers, and in 
some typhoid epidemics many cases have occurred. 

(c) Tetany may follow removal of the thyroid gland. Thirteen cases, 
for example, followed 78 operations on enlarged thyroid in Billroth's clinic, 
and 6 of them proved fatal. James Stewart has reported an instance in 
which with the tetany there were symptoms of myxcedema, and no trace of 
the thyroid gland. Eemoval of the thyroid in dogs is followed by tetany. 

(d) And, lastly, there is a form of tetany which is associated with dila- 
tation of the stomach, particularly after the organ has been washed out. 

On this continent true tetany is an extremely rare disease. Griffith 
has collected 72 cases, among which, however, cases of carpo-pedal spasm 
are included. 

The nature of the disease is unknown; certain forms depend undoubt- 
edly on loss of the function of the thyroid gland. 

Symptoms. — In cases associated with general debility or in children 
with rickets the spasm is limited to the hands and feet. The fingers are 
bent at the metacarpo-phalangeal joint, extended at the terminal joints, 
pressed close together, and the thumb is contracted in the palm of the 
hand. The wrist is flexed, the elbows are bent, and the arms are folded 
over the chest. In the lower limbs the feet are extended and the toes ad- 
ducted. The muscles of the face and neck are less commonly involved, 
but in severe cases there may be trismus, and the angles of the mouth are 
drawn out. The skin of the hands and feet is sometimes tense and cedem- 
atous. The spasms are usually paroxysmal and last for a variable time. 
In children the attack may pass off in a few hours. In some of the severer 
chronic eases in adults the stiffness and contracture may continue or even 
increase for many days, and the attack may last as long as two weeks. In 
the acute cases the temperature may be elevated and the pulse quickened. 
In the severe paroxysms there may be involvement of the muscles of the 
back and of the thorax, inducing dyspnoea and cyanosis. Certain addi- 
tional features, valuable in diagnosis, are present. 

Trousseau's symptom: " So long as the attack is not over, the parox- 
ysms may be reproduced at will. This is effected by simply compress- 
ing the affected parts, either in the direction of their principal nerve 
trunks or over their blood-vessels, so as to impede the venous or arterial 
circulation." 

Chovstek's symptom is shown in the remarkable increase in the me- 
chanical excitability of the motor nerves. A slight tap, for example, in 
the course of the facial nerve will throw the muscles to which it is dis- 
tributed into active contraction. Erb has shown that the electrical irrita- 
bility of the nerves is also greatly increased, and Hofmann has demon- 



HYSTERIA. 



1111 



strated the heightened excitability of the sensory nerves, the slightest 
pressure on which may cause paresthesia in the region of distribution. 

Diagnosis. — The disease is readily recognized. It is a mistake to call 
instances of carpo-pedal spasm of children true tetany. It is common to 
find in rickety children or in cases of severe gastro-intestinal catarrh a 
transient spasm of the fingers or even of the arms. By many authors these 
are considered cases of mild tetany, and there are all grades in rickety chil- 
dren between the simple carpo-pedal spasm and the condition in which 
the four extremities are involved; but it is well, I think, to limit the term 
tetany to the severer affection. 

With true tetanus the disease is scarcely ever confounded, as the com- 
mencement of the spasm in the extremities, the attitude of the hands, and 
the etiological factors are very different. Hysterical contractures are usually 
unilateral. 

Treatment. — In the case of children the condition with which the 
tetany is associated should be treated. Baths and cold sponging are recom- 
mended and often relieve the spasm as promptly as in child-crowing. Bro- 
mide of potassium may be tried. In severe cases chloroform inhalations 
may be given. Massage, electricity, and the spinal ice-bag have also been 
used with success. Cases, however, may resist all treatment, and the spasms 
recur for many years. The thyroid extract should be tried. Gottstein re- 
ports relief in a case of long standing, and Bramwell reports one case of 
operative tetany and one of the idiopathic form successfully treated in 
this way. 

XI. HYSTERIA. 

Definition. — A state in which ideas control the body and produce 
morbid changes in its functions (Mobius). 

Etiology. — The affection is most common in women, and usually ap- 
pears first about the time of puberty, but the manifestations may continue 
until the menopause, or even until old age. Men, however, are by no means 
exempt, and of late years hysteria in the male has attracted much attention. 
It occurs in all races, but is much more prevalent, particularly in its 
severer forms, in members of the Latin race. In this country the milder 
grades are common, but the graver forms are rare in comparison with the 
frequency with which they are seen in France. 

Children under twelve years of age are not very often affected, but the 
disease may be well marked as early as the fifth or sixth year. One of 
the saddest chapters in the history of human deception, that of the 
Salem witches, might be headed hysteria in children, since the tragedy 
resulted directly from the hysterical pranks of girls under twelve years 
of age. 

Of predisposing causes, two are important — heredity and education. 
The former acts by endowing the child with a mobile, abnormally sensi- 
tive nervous organization. We see cases most frequently in families with 
marked neuropathic tendencies, the members of which have suffered from 
neuroses of various sorts. Education at home too often fails to inculcate 



1112 



DISEASES OF THE NERVOUS SYSTEM. 



habits of self-control. A child grows to girlhood with an entirely errone- 
ous idea of her relations to others, and accustomed to have every whim 
gratified and abundant sympathy lavished on every woe, however trifling, 
she reaches womanhood with a moral organization unfitted to withstand 
the cares and worries of every-day life. At school, between the ages of 
twelve and fifteen, the most important period in her life, when the vital 
energies are absorbed in the rapid development of the body, she is often 
cramming for examinations and cooped in close school-rooms for six or 
eight hours daily. The result too frequently is an active, bright mind in 
an enfeebled body, ill' adapted to subserve the functions for which it was 
framed, easily disordered, and prone to react abnormally to the ordinary 
stimuli of life. Among the more direct influences are emotions of various 
kinds, fright occasionally, more frequently love affairs, grief, and domestic 
worries. Physical causes less often bring on hysterical outbreaks, but they 
may follow directly upon an injury or develop during the convalescence 
from an acute illness or be associated with disease of the generative organs. 
The name hysteria indicates how important was believed to be the part 
played by the uterus in the causation of the disease. Opinions differ a 
good deal on this question, but undoubtedly in many cases there are ova- 
rian and uterine disorders the rectification of which sometimes cures the 
disease. Sexual excess, particularly masturbation, is an important factor, 
both in girls and boys. 

Symptoms. — A useful division is into the convulsive and non-convul- 
sive varieties. 

Convulsive Hysteria. — (a) Minor Forms. — The attack most commonly 
follows emotional disturbance. It may set in suddenly or be preceded by 
symptoms, called by the laity " hysterical," such as laughing and crying 
alternately, or a sensation of constriction in the neck, or of a bail rising in 
the throat — the globus hystericus. Sometimes, preceding the convulsive 
movements, there may be painful sensations arising from the pelvic, ab- 
dominal, or thoracic regions. From the description these sensations re- 
semble aurse. They become more intense with the rising sensation of 
choking in the neck and difficulty in getting breath, and the patient falls 
into a more or less violent convulsion. It will be noticed that the fall is 
not sudden, as in epilepsy, but the subject goes down, as a rule, easily, often 
picking a soft spot, like a sofa or an easy-chair, and in the movements 
apparently exercises care to do herself no injury. Yet at the same time 
she appears to be quite unconscious. The movements are clonic and dis- 
orderly, consisting of to-and-fro motions of the trunk or pelvic muscles, 
while the head and arms are thrown about in an irregular manner. The 
paroxysm after a few minutes slowly subsides, then the patient becomes 
emotional, and gradually regains consciousness. When questioned the 
patient may confess to having some knowledge of the events which have 
taken place, but, as a rule, has no accurate recollection. During the at- 
tack the abdomen may be much distended with flatus, and subsequently a 
large amount of clear urine may be passed. These attacks vary greatly in 
character. There may be scarcely any movements of the limbs, but after 
a nerve storm the patient sinks into a torpid, semi-unconscious condition, 



HYSTERIA. 



1113 



from which she is roused with great difficulty. In some cases from this 
state the patient passes into a condition of catalepsy. 

(b) Major Forms; Hystero-epilepsy. — This condition has been especially 
studied by Charcot and his pupils. Typical instances passing through the 
various phases are very rare in this country. The attack is initiated by 
certain prodromata, chiefly minor hysterical manifestations, either foolish 
or unseemly behavior, excitement, sometimes dyspeptic symptoms with 
tympanites, or frequent micturition. Areas of hyperesthesia may at this 
time be marked, the so-called hysterogenic spots so elaborately described 
by Eichet. These are usually symmetrical and situated over the upper 
dorsal vertebra, and in front in a series of symmetrically placed spots on 
the chest and abdomen, the most marked being those in the inguinal re- 
gions over the ovaries. Painful sensations or a feeling of oppression and a 
globus rising in the throat may be complained of prior to the onset of the 
convulsion, which, according to French writers, has four distinct stages: 
(1) Epileptoid condition, which closely simulates a true epileptic attack 
with tonic spasm (often leading to opisthotonos), grinding of the teeth, 
congestion of the face, followed by clonic convulsions, gradual relaxation, 
and coma. This attack lasts rather longer than a true epileptic attack. (2) 
Succeeding this is the period which Charcot has termed clownism, in which 
there is an emotional display and a remarkable series of contortions or of 
cataleptic poses. (3) Then in typical cases there is a stage in which the 
patient assumes certain attitudes expressive of the various passions — ecstasy, 
fear, beatitude, or erotism. (4) Finally consciousness returns and the pa- 
tient enters upon a stage in which she may display very varied symp- 
toms, chiefly manifestations of a delirium with the most extraordinary 
hallucinations. Visions are seen, voices heard, and conversations held with 
imaginary persons. In this stage patients will relate with the utmost 
solemnity imaginary events, and make extraordinary and serious charges 
against individuals. This sometimes gives a grave aspect to these seizures, 
for not only will the patient at this stage make and believe the state- 
ments, but when recovery is complete the hallucination sometimes per- 
sists. We seldom see in this country attacks having this orderly se- 
quence. Much more commonly the convulsions succeed each other at 
intervals for several days in succession. Here is a striking difference 
between hystero-epilepsy and true epilepsy. In the latter the status 
epilepticus, if persistent, is always serious, associated with fever, and fre- 
quently fatal, while in hystero-epilepsy attacks may recur for days with- 
out special danger to life. After an attack of hystero-epilepsy the pa- 
tient may sink into a state of trance or lethargy, in which she may remain 
for days. 

Non-convulsive Forms. — So complex and varied is the clinical picture of 
hysteria that various manifestations are best considered according to the 
systems which are involved. 

(1) Disorders of Motion. — (a) Paralyses. — These may bo hemiplegia, 
paraplegic, or monoplegic. Hysterical diplegia is extremely rare. The 
paralysis either sets in abruptly or gradually, and may take weeks to attain 
its full development. There is no type or form of organic paralysis which, 



1114 



DISEASES OF THE NERVOUS SYSTEM. 



may not be simulated in hysteria. According to Weir Mitchell, trie hemi- 
plegias are most frequent in the ratio of four on the left to one on the 
right side. The face is not affected; the neck may be involved, but the 
leg suffers most. Sensation is either lessened or lost on the affected side. 
The hysterical paraplegia is more common than hemiplegia. The loss of 
power is not absolute; the legs can usually be moved, but do not support 
the patient. The reflexes may be increased, though the knee-jerk is often 
normal. A spurious ankle clonus may sometimes be present. The feet 
are usually extended and turned inward in the equino-varus position. The 
muscles do not waste and the electrical reactions are normal. Other mani- 
festations, such as paralysis of the bladder or aphonia, are usually associ- 
ated with the hysterical paraplegia. Hysterical monoplegias may be facial, 
crural, or brachial. A condition of ataxia sometimes occurs with paresis. 
The incoordination may be a marked feature, and there are usually sensory 
manifestations. 

(b) Contractures and Spasms. — An extraordinary variety of spasmodic 
affections occurs in hysteria, of which the most common are the follow- 
ing: The hysterical contractures may attack almost any group of volun- 
tary muscles and be of the hemiplegic, paraplegic, or monoplegic type. 
They may come on suddenly or slowly, persist for months or years, and 
disappear rapidly. The contracture is most commonly seen in the arm, 
which is flexed at the elbow and wrist, while the fingers tightly grasp the 
thumb in the palm of the hand; more rarely .the terminal phalanges are 
hyperextended as in athetosis. It may occur in one or in both legs, more 
commonly the former. The ankle clonus is present; the foot is inverted 
and the toes are strongly flexed. These cases may be mistaken for lateral 
sclerosis and the difficulty in diagnosis may really be very great. The 
spastic gait is very typical, and with the exaggerated knee-jerk and ankle 
clonus the picture may be characteristic. In 1879 I frequently showed 
such a case at the Montreal General Hospital as a typical example of lat- 
eral sclerosis. The condition persisted for more than eighteen months and 
then disappeared completely. Other forms of contracture may be in the 
muscles of the hip, shoulder, or neck; more rarely in those of the jaws — 
hysterical trismus — or in the tongue. Remarkable indeed are the local con- 
tractures in the diaphragm and abdominal muscles, producing a phantom 
tumor, in which just below and in the neighborhood of the umbilicus is a 
firm, apparently solid growth. According to Gowers, this is produced by 
relaxation of the recti and a spasmodic contraction of the diaphragm, to- 
gether with inflation of the intestines with gas and an arching forward of 
the vertebral column. They are apt to occur in middle-aged women about 
the menopause, and are frequently associated with the symptoms of spu- 
rious pregnancy — pseudo-cyesis. The resemblance to a tumor may be strik- 
ing, and I have known skilful diagnosticians to be deceived. The only 
safeguard is to be found in complete anaesthesia, when the tumor entirely 
disappears. Some years ago I went by chance into the operating-room of 
a hospital and found a patient on the table under chloroform and the sur- 
geon prepared to perform ovariotomy. The tumor, however, had com-' 
pletely disappeared with full anaesthesia. Mitchell has reported an instance 



HYSTERIA. 



1115 



of a phantom tumor in the left pectoral region just above the breast, which 
was tender, hard, and dense. 

Clonic spasms are more common in hysteria in this country than con- 
tractures. The following are the important forms: Rhythmic hysterical 
spasm. This, unfortunately, is sometimes known as rhythmic chorea or 
hysterical chorea. The movements may be of the arm, either flexion and 
extension, or, more rarely, pronation and supination. Clonic contractions 
of the sterno-cleido-mastoid or of the muscles of the jaws or of the rota- 
tory muscles of the head may produce rhythmic movements of these parts. 
The spasm may be in one or both psoas muscles, lifting the leg in a rhythmic 
manner eight or ten times in a minute. In other instances the muscles 
of the trunk are affected, and every few moments there is a bowing move- 
ment — salaam convulsions — or the muscles of the back may contract, caus- 
ing strong arching of the vertebral column and retraction of the head. 
These movements may often alternate, as in a case in my wards, in which 
the patient on fine days had regular salaam convulsions, while on wet days 
the rhythmic spasm was in the muscles of the back and neck. Mitchell 
has described a rotatory spasm in which the patient rotated involuntarily, 
usually to the left. More unusual cases are those in which the contractions 
closely simulate paramyoclonus multiplex. Hysterical athetosis is a rare 
form of spasm. Tremor may be a purely hysterical manifestation, occur- 
ring either alone or with paralysis and contracture. It most commonly in- 
volves the hands and arms; more rarely the head and legs. The move- 
ments are small and quick. In the type Rendu the tremor may or may 
not persist during repose, but it is increased or provoked by volitional move- 
ments. Volitional or intentional tremor may exist, simulating closely 
the movements of insular sclerosis. Buzzard states that many instances 
of .this disease in young girls are mistaken for hysteria. 

(2) Disorders of Sensation. — Anaesthesia is most common, and usually 
confined to one half of the body. It may not be noticed by the patient. 
Usually it is accurately limited to the middle line and involves the mucous 
surfaces and deeper parts. The conjunctiva, however, is often spared. 
There may' be hemianopia. This symptom may come on slowly or follow 
a convulsive attack. Sometimes the various sensations are dissociated and 
the anesthesia may be only to pain and to touch. The skin of the affected 
side is usually pale and cool, and a pin-prick may not be followed by blood. 
With the loss of feeling there may be loss of muscular power. Curious 
trophic changes may be present, as in an interesting case of Weir Mitchell's, 
in which there was unilateral swelling of the hemiplegic side. 

A phenomenon to which much attention has been paid is that of trans- 
ference. By metallotherapy, the application of certain metals, the ana3S- 
thesia or analgesia can be transferred to the other side of the body. It 
has been shown, however, that this phenomenon may be caused by the 
electro-magnet and by wood and various other agents, and is probably en- 
tirely a mental effect. The subject has no practical importance, but it 
remains an interesting and instructive chapter in Gallic medical history. 

Hyperesthesia. — Increased sensitiveness and pains occur in various parts 
of the body. One of the most frequent complaints is of pain in the head, 



1116 



DISEASES OF THE NERVOUS SYSTEM. 



usually over the sagittal suture, less frequently in the occiput. This is 
described as agonizing, and is compared to the driving of a nail into the 
part; hence the name clavus hystericus. Neuralgias are common. Hyper- 
aesthetic areas, the hysterogenic points, exist on the skin of the thorax and 
abdomen, pressure upon which may cause minor manifestations or even 
a convulsive attack. Increased sensitiveness exists in the ovarian region, 
but is not peculiar to hysteria. Pain in the back is an almost constant 
complaint of hysterical patients. The sensitiveness may be limited to cer- 
tain spinous processes, or it may be diffuse. In hysterical women the pains 
in the abdomen may simulate those of gastralgia and of gastric ulcer, or 
the condition may be almost identical with that of peritonitis; more rarely 
the abdominal pains closely resemble those of appendix disease. 

Special Senses. — Disturbances of taste and smell are not uncommon 
and may cause a good deal of distress. Of ocular symptoms, retinal hyper- 
esthesia is the most common, and the patients always prefer to be in a 
darkened room. Eetraction of the field of vision is common and usually 
follows a convulsive seizure. It may persist for years. The color percep- 
tion may be normal even with complete anesthesia, and in this country 
the achromatopsia does not seem to be nearly so common an hysterical 
manifestation as in Europe. Hysterical deafness may be complete and 
may alternate or come on at the same time with hysterical blindness. 
Hysterical amaurosis may occur in children. One must carefully distin- 
guish between functional loss of power and simulation. 

(3) Visceral Manifestations. — Respiratory Apparatus. — Of disturbances 
in the respiratory rhythm, the most frequent, perhaps, is an exaggeration 
of the deeper breath, which is taken normally every fifth or sixth inspira- 
tion, or there may be a " catching " breathing, such as is seen when cold 
water is poured over a person. In hysterical dyspnoea there is no special 
distress and the pulse is normal. In what is known as the syndrome of 
Briquet there is shortness of breath, suppression of the voice, and paralysis 
of the diaphragm. The anhelation is extreme. Among laryngeal mani- 
festations aphonia is frequent and may persist for months or even years 
without other special symptoms of the disease. Spasm of the muscles may 
occur with violent inspiratory efforts and great distress, and may even lead 
to cyanosis. Hiccough, or sounds resembling it, may be present for weeks 
or months at a time. Among the most remarkable of the respiratory mani- 
festations are the hysterical cries. These may mimic the sounds produced 
by animals, such as barking, mewing, or grunting, and in France epidemics 
of them have been repeatedly observed. Extraordinary cries may be pro- 
duced, either inspiratory or expiratory. I saw at Wagner's clinic at Leipsic 
a girl of thirteen or fourteen, who had for many weeks given utterance to 
a remarkable inspiratory cry somewhat like the whoop of whooping-cough, 
but so intense that it was heard at a long distance. It was incessant, and 
the girl was worn to a skeleton. Attacks of gaping, yawning, and sneezing 
may also occur. 

The hysterical cough is a frequent symptom, particularly in young 
girls. It may occur in paroxysms, but is often a dry, persistent, croaking 
cough, extremely monotonous and unpleasant to hear. Sir Andrew Clark 



HYSTERIA. 



1117 



has called attention to a loud, barking cough (cynobex hebetica) occurring 
about the time of puberty, chiefly in boys belonging to neurotic families. 
The attacks, which last about a minute, recur frequently. 

There is a peculiar form of haemoptysis which may be very deceptive 
and lead to the diagnosis of pulmonary disorders. Wagner describes the 
sputum as a pale-red fluid — not so bright in color as in ordinary haemop- 
tysis; on settling it presents a reddish-brown sediment. It contains par- 
ticles of food, pavement epithelium, red corpuscles, and micrococci, but 
no cylindrical or ciliated epithelium. It probably comes from tire mouth 
or pharynx. 

Digestive System. — Disturbed or depraved appetite, dyspepsia, and gas- 
tric pains are common in hysterical patients. The patient may have diffi- 
culty in swallowing the food, apparently from spasm of the gullet. There 
are instances in which the food seems to be expelled before it reaches the 
stomach. In other cases there is incessant gagging. In the hysterical 
vomiting the food is regurgitated without much effort and without nausea. 
This feature may persist for years without great disturbance of nutrition. 
The most striking and remarkable digestive disturbance in hysteria is the 
anorexia nervosa described by Sir William Gull. " To call it loss of appe- 
tite — anorexia — but feebly characterizes the symptom. It is rather an 
annihilation of appetite, so complete that it seems in some cases impossible 
ever to eat again. Out of it grows an antagonism to food which results 
at last and in its worst forms in spasm on the approach of food, and this in 
turn gives rise to some of those remarkable cases of survival for long periods 
without food" (Mitchell). As this goes on there may be an extreme de- 
gree of muscular restlessness, so that the patients wander about until ex- 
hausted. Nothing more pitiable is to be seen in practice than an ad- 
vanced case of this sort. It is usually in a young girl, sometimes as early 
as the eleventh or twelfth, more commonly between the fifteenth and twen- 
tieth years. The emaciation is frightful, and scarcely exceeded by that of 
cancer of the oesophagus. The patient finally takes to bed, and in extreme 
cases lies upon one side with the thighs and legs flexed, and contractures 
may occur. Food is either not taken at all or only upon urgent compul- 
sion. The skin becomes 'wasted, dry, and covered with bran-like scales. 
No food may be taken for several weeks at a time, and attempts to feed 
may be followed by severe spasms. Although the condition looks so alarm- 
ing, these cases, when removed from their home surroundings and treated 
by Weir Mitchell's method, sometimes recover in a remarkable way. Death, 
however, may follow with extreme emaciation. In a fatal case under my 
care the girl weighed only 49 pounds. No lesions were found post mortem. 

Among intestinal symptoms flatulency is one of the most distressing, 
and is usually associated with the condition of peristaltic unrest (Kuss- 
manl). Frequent discharges of faeces may be clue to disturbance in either 
the small or large bowel. An obstinate form of diarrhoea is found in some 
hysterical patients, which proves very intractable and is associated espe- 
cially with the taking of food. It seems an aggravated form of the loose- 
ness of bowels to which so many nervous people are subject on emotion 
or the tendency which some have to diarrhoea immediately after eating. 



1118 



DISEASES OF THE NERVOUS SYSTEM. 



An entirely different form is that produced by what Mitchell calls the irri- 
table rectum, in which scybala are passed frequently during the day, some- 
times with great violence. Constipation is more frequent, however, and 
may be due to a loss of power in the muscles of the bowel, or in the ab- 
dominal muscles. In extreme cases the bowels may not be moved for. two 
or three weeks, leading to great accumulation of fseces. Other disturbances 
are ano-spasm or intense pain in the rectum apart from any fissure. 

Cardio-vascular. — Eapid action of the heart on the slightest emotion, 
with or without the subjective sensation of palpitation, is often a source 
of great distress. A slow pulse is less frequent. Pains about the heart 
may simulate angina, the so-called hysterical or pseudo-angina, which has 
already been considered. Flushes in various parts are among the most 
common symptoms. Sweating occasionally occurs. 

Among the more remarkable vaso-motor phenomena are the so-called 
stigmata or haemorrhages in the skin, such as were present in the cele- 
brated case of Louise Lateau. In many cases these are undoubtedly fraud- 
ulent, but if, as appears credible, such bleeding may exist in the hypnotic 
trance, there seems no reason to doubt its occurrence in the trance of pro- 
longed religious ecstasy. 

Joint Affections. — To Sir Benjamin Brodie and Sir James Paget we 
owe the recognition of these extraordinary manifestations of hysteria. Per- 
haps no single affection has brought more discredit upon the profession, 
for the eases are very refractory, and finally fall into the hands of a char- 
latan or faith-healer, under whose touch the disease may disappear at once. 
Usually it affects the knee or the hip, and may follow a trifling injury. 
The joint is usually fixed, sensitive, and swollen. The surface may be 
cool, but sometimes the local temperature is increased. To the touch it 
is very sensitive and movement causes great pain. In protracted cases the 
muscles about the joint are somewhat wasted, and in consequence it looks 
larger. The pains are often nocturnal, at which time the local tempera- 
ture may be much increased. While, as a rule, neuromimetic joints yield 
to proper management, there are interesting instances in the literature in 
which organic change has succeeded the functional disturbance. In the 
remarkable case reported in Weir Mitchell's lectures, the hysterical fea- 
tures were pronounced, and, on account of the chronicity, the disease of 
the knee-joint was considered organic by such an authority as Billroth. 
Sands found the joint surfaces normal, and the thickening to be due to 
inflammatory products outside the capsule. 

Intermittent hydrarthrosis may be a manifestation of hysteria, occur- 
ring in the knee or other joints, sometimes with transient paresis. 

Mental Symptoms. — The psychical condition of an hysterical patient 
is always abnormal, and the disease occupies the ill-defined territory be- 
tween sanity and insanity. In a large number of cases the patients are 
really insane, particularly in the perversion witnessed in the moral sphere. 
Not the slightest dependence can be placed upon their statements, and 
they will for months or years deceive friends, relatives, and physician. 
This appears to result partly, but not wholly, from a morbid craving for 
£ympathy. It is really due to an entire unhinging of the moral nature. 



HYSTERIA. 



1119 



Hysterical patients may become insane and display persistent hallu- 
cinations and delirium, alternating perhaps with emotional outbursts of 
an aggravated character. For weeks or months they may be confined to 
bed, entirely oblivious to their surroundings, with a delirium which may 
simulate that of delirium tremens, particularly in being associated with 
loathsome and unpleasant animals. The nutrition may be maintained, 
but in these cases there is always a very heavy, foul breath. With seclu- 
sion and care recovery usually takes place within three or four months. 
At the onset of these attacks and during convalescence the patients must 
be incessantly watched, as a suicidal tendency is by no means uncommon. 
I have been accustomed to speak of this condition as the status hystericus. 

Of hysterical manifestations in the higher centres that of trance is the 
most remarkable. This may develop spontaneously without any convul- 
sive seizure, but more frequently, in this country at least, it follows hys- 
teroid attacks. Catalepsy, a condition in which the limbs are plastic and 
remain in any position in which they are placed, may be present. 

The Metabolism in Hysteria. — The studies of Gilles de la Tourette and 
Cathelineau, under Charcot's direction, have shown that in the ordinary 
forms of hysteria the urine does not show quantitative or qualitative 
changes, but in the severer types, characterized by convulsions, etc., there 
are important modifications: reduction in the urates and phosphates; the 
ratio of the earthy to the alkaline phosphates, normally 1 : 3, is 1 : 2, or 
even 1:1. The urine is also reduced in amount. They think that these 
changes might sometimes serve to differentiate convulsive hysteria from 
epilepsy, in which there is always an increase in the solid constituents after 
a seizure. 

Hysterical Fever. — In hysteria the temperature, as a rule, is normal. 
The cases with fever may be grouped as follows: (a) Instances in which 
the fever is the sole manifestation. These are rare, but I have seen at 
least two cases in which the chronic course, the retention of the nutrition, 
and the entirely negative condition of the organs left no other diagnosis 
possible. In a case recently under observation the patient has had for four 
or five years an afternoon rise of temperature, reaching usually to 102° or 
103°. She was well nourished and presented no pronounced hysterical 
symptoms, but there was a marked neurotic history on one side and a form 
of interrupted sighing respiration so often seen in hysteria. 

Cases of hysterical fever with spurious local manifestations. These 
are very troublesome and deceptive cases. The patient may be suddenly 
taken ill with pain in various regions and elevation of temperature. The 
case may simulate meningitis. There may be pain in the head, vomiting, 
contracted pupils, and retraction of the neck — symptoms which may per- 
sist for weeks — and some anomalous manifestation during convalescence 
may alone indicate to the physician that he has had to deal with a ease of 
hysteria, and has not, as he perhaps flattered himself, cured a case of men- 
ingitis. Mary Putnam Jacobi, in a recent article on hysterical fever, men- 
tions a case in the service of Cornil which was admitted with dyspnoea, 
slight cyanosis, and a temperature of 39° C. The condition proved to be 
hysterical. There is also an hysterical pseudo-phthisis with pain in the 



1120 



DISEASES OF THE NERVOUS SYSTEM. 



chest, slight fever, and the expectoration of a blood-stained mucus. The 
cases of hysterical peritonitis may also show fever. 

(c) Hysterical Hyperpyrexia. — It is a suggestive fact that the cases of 
paradoxical temperatures reported of late years, in which the thermometer 
has registered 112° to 120° or more, have been in women. Fraud has been 
practised in some of these, but others have to be accepted, though their 
explanation is impossible under our known laws. Jacobi has reported a 
case in which the temperature rose to 148° F. (65.5° C). The Omaha 
case, in which the temperature was recorded at 170° F., has, I am informed 
on good authority, proved a fraud. 

Diagnosis. — Inquiry into the occurrence of previous manifestations 
and the mental conditions may give important information. These ques- 
tions, as a rule, should not be asked the mother, who of all others is least 
likely to give satisfactory information about the patient's condition. The 
occurrence of the globus hystericus, of emotional attacks, of weeping and 
crying, are always suggestive. The points of difference between the con- 
vulsive attacks and true epilepsy were referred to in their description, 
and as a rule little difficulty is experienced in distinguishing between the 
two conditions. The hysterical paralyses are very variable and apt to be 
associated with anaesthesia. The contractures may at times be very decep- 
tive, but the occurrence of areas of anaesthesia, of retraction of the visual 
field, and the development of minor hysterical manifestations, give valua- 
ble indications. The contractures disappear under full anaesthesia. Spe- 
cial care must be taken not to confound the spastic paraplegia of hysteria 
with lateral sclerosis. 

The visceral manifestations are usually recognized without much diffi- 
culty. The practitioner has constantly to bear in mind the strong tendency 
in hysterical patients to practise deception. 

Treatment. — The prophylaxis in hysteria may be gathered from the 
remarks on the relation of education to the disease. The successful treat- 
ment of hysteria demands qualities possessed by few physicians. The first 
element is a due appreciation of the nature of the disease on the part of 
the physician and friends. It is pitiable to think of the misery which has 
been inflicted on these unhappy victims by the harsh and unjust treat- 
ment which has resulted from false views of the nature of the trouble; 
on the other hand, worry and ill-health, often the wrecking of mind, 
body, and estate, are entailed upon the near relatives in the nursing of a 
protracted case of hysteria. The minor manifestations, attacks of the 
vapors, the crying and weeping spells, are not of much moment and rarely 
require treatment. The physical condition should be carefully looked into 
and the mode of life regulated so as to insure system and order in every- 
thing. A congenial occupation offers the best remedy for many of these 
manifestations. Any functional disturbance should be attended to and a 
course of tonics prescribed. Special attention should be paid to the action 
of the bow-els. 

Valerian and asafcetida are often of service. For the pains in various 
parts, particularly in the back, the thermo-cautery and static electricity 
will be found invaluable. Morphia should be withheld. In the convulsive 



HYSTERIA. 



1121 



seizures, particularly in the minor forms, it is often best, after settling the 
patient comfortably, to leave her. When she comes to, and finds herself 
alone and without sympathy, the attacks are less likely to be repeated. 
There is, as a rule, no cure for the hysterical manifestations of women, 
otherwise in good health, who are, as Mitchell says, " fat and ruddy, with 
sound organs and good appetites, but ever complain of pains and aches, 
and ever liable on the least emotional disturbance to exhibit a quaint vari- 
ety of hysterical phenomena." 

To treat hysteria as a physical disorder is, after all, radically wrong. It 
is essentially a mental and emotional anomaly, and the important element 
in the treatment is moral control. At home, surrounded by loving relatives 
who misinterpret entirely the symptoms and have no appreciation of the 
nature of the disease, the severer forms of hysteria can rarely be cured. The 
necessary control is impossible; hence the special value of the method in- 
troduced by Weir Mitchell, which is particularly applicable to the advanced 
cases which have become chronic and bedridden. The treatment consists 
in isolation, rest, diet, massage, and electricity. Separation from friends 
and sympathetic relatives must be absolute, and can rarely, if ever, be 
obtained in the individual's home. An essential element in the treatment 
is an intelligent nurse. No small share of the success which has attended 
the author of this plan has been due to the fact that he has persistently 
chosen as his allies bright, intelligent women. The details of the plan are 
as follows: The patient is confined to bed and not allowed to get up, nor, 
at first, in aggravated cases, to read, write, or even to feed herself. Massage 
is used daily, at first for twenty minutes or half an hour, subsequently for 
a longer period. It is essential as a substitute for exercise. The induction 
current is applied to the various muscles and to the spine. Its use, how- 
ever, is not so essential as that of massage. The diet may at first be entirely 
of milk, 4 ounces every two hours. It is better to give skimmed milk, 
and it may be diluted with soda water or barley water and, if necessary, 
peptonized. After a week or ten days the diet may be increased, the 
amount of milk still being kept up. A chop may be given at midday, a cup 
of coffee or cocoa with toast or bread and butter or a biscuit with the milk. 
The patients usually fatten rapidly as the solid food is added, and with 
the gain there is, as a rule, a diminution or cessation of the nervous symp- 
toms. The milk is the essential element in the diet, and is in itself amply 
sufficient. 

The remarkable results obtained by this method are now universally 
recognized. The. plan is more applicable to the lean than to fat, flabby 
hysterical patients. Not only is it suitable for the more obstinate varieties 
of hysteria with, bodily manifestations, but in the cases with mental symp- 
toms the seclusion and separation from relatives and friends are particu- 
larly advantageous. In the hysterical vomiting Debove's method of forced 
feeding may be used with benefit. For the innumerable minor manifesta- 
tions of hysteria and for the simulations the indications for treatment are 
usually clear. Of late, hypnotism has been extensively used in the treat- 
ment of hysteria. Occasionally in cases of hysterical contractions or paraly- 
sis it is of benefit, but any one who has seen the development of this method 
70 



1122 



DISEASES OF THE NERVOUS SYSTEM. 



as practised at present in France must feel that it is a two-edged sword and 
that the constant repetition in the same patient is fraught with danger. 
In the cases in which we have tried it here the success has not been marked. 



XII. NEURASTHENIA. 

Definition. — A condition of weakness or exhaustion of the nervous 
system, giving rise to various forms of mental and bodily inefficiency. 

The term, an old one, but first popularized by Beard, covers an ill-de- 
fined, motley group of symptoms, which may be either general and the ex- 
pression of derangement of the entire system, or local, limited to certain 
organs; hence the terms cerebral, spinal, cardiac, and gastric neurasthenia. 

Etiology. — The causes may be grouped as hereditary and acquired. 

(a) Hereditary. — We do not all start in life with the same amount of 
nerve capital. Parents who have led irrational lives, indulging in excesses 
of various kinds, or who have been the subjects of nervous complaints or 
of mental trouble, may transmit to their children an organization which is 
defective in what, for want of a better term, we must call "nerve force/' 
Such individuals start handicapped with a neuropathic predisposition, and 
furnish a considerable proportion of our neurasthenic patients. As van 
Gieson sonorously puts it, " the potential energies of the higher constella- 
tions of their association centres have been squandered by their ancestors." 

Besides such forms of hereditary neuropathy, which we have to look 
upon as instances of injury to the germ-plasm derived from one or both 
of the parents, there have to be considered those cases in which during 
intra-uterine life there have been conditions which interfered with the 
proper development and nutrition of the embryo. So long as these indi- 
viduals are content to transact a moderate business with their life capital, 
all may go well, but there is no reserve, and in the exigencies of modern life 
these small capitalists go under and come to us as bankrupts. 

(b) Acquired. — The functions, though perverted most readily in persons 
who have inherited a feeble organization, may also be damaged in persons 
with no neuropathic predisposition by exercise which is excessive in pro- 
portion to the strength — i. e., by strain. The cares and anxieties attendant 
upon the gaining of a livelihood may be borne without distress, but in many 
persons the strain becomes excessive and is first manifested as worry. The 
individual loses the distinction between essentials and non-essentials, trifles 
cause annoyance, and the entire organism reacts with unnecessary readiness 
to slight stimuli, and is in a state which the older writers called irritable 
weakness. If such a condition be taken early and the patient given rest, 
the balance is quickly restored. In this group may be placed a large pro- 
portion of the neurasthenics which we see in this country, particularly 
among business men, teachers, and journalists. Neurasthenia may follow 
the infectious diseases, particularly influenza, typhoid fever, and syphilis. 
The abuse of certain drugs, alcohol, tobacco, morphine may lead to a high 
grade of neurasthenia, though the drug habit is more often a result rather 
than a cause of the neurasthenia. Other causes more subtle, yet potent, and 



NEURASTHENIA. 



1123 



less easily dealt with, are the worries attendant upon love affairs, religious 
doubts, and the sexual passion. Sexual excesses have undoubtedly been 
exaggerated as a cause of neurasthenia, but that they are responsible in a 
number of instances is certain. 

The traumatic forms, especially those following upon railway accidents, 
will be separately considered. 

Symptoms. — These are extremely varied, and may be general or 
localized; more often a combination of both. The appearance of the pa- 
tient is suggestive, sometimes characteristic, but difficult to describe. Im- 
portant information can be gained by the physician if he observe the 
patient closely as he enters the room— the way he is clothed, the manner 
in which he holds his body, his facial expression, and the humor which he 
is in. Loss of weight and slight anaemia may be present. The physical 
debility may reach a high grade and the patient may be confined to bed. 
Mentally the patients are usually low-spirited and despondent; women are 
frequently emotional. 

The local symptoms may dominate the situation, and there have accord- 
ingly been described a whole series of types of the disease— cerebral, spinal, 
cardio-vascular, gastric, and sexual. In all forms there is a striking lack of 
accordance between the symptoms of which the patient complains and the 
objective changes discoverable by the physician. In nearly every clinical type 
of the disease the predominant symptoms are referable to pathological sensa- 
tions and the psychic effects of these. Imperfect sleep is also complained 
of by a majority of patients, or, if not complained of, is found to exist on 
inquiry. 

In the cerebral or psychic form the symptoms are chiefly connected with 
an inability to perform the ordinary mental work. Thus a row of figures 
cannot be correctly added, the dictation or the writing of a few letters is a 
source of the greatest worry, the transaction of petty details in business is 
a painful effort, and there is loss of power of fixed attention. With this 
condition there may be no headache, the appetite may be good, and the 
patient may sleep well. As a rule, however, there are sensations of fulness 
and weight or flushes, if not actual headache. Sleeplessness is a frequent 
concomitant of the cerebral form, and may be the first manifestation. 
Some of these patients are good-tempered and cheerful, but a majority are 
moody, irritable, and depressed. 

Hyperesthesia, especially to sensations of pain, is one of the main char- 
acteristics of almost all neurasthenic individuals. The sensations are nearly 
always referred to some special region of the body — the skin, eye muscles, 
the joints, the blood-vessels, or the viscera. It is frequently possible to 
localize a number of points painful to pressure (Valleix's points). In some 
patients there is marked vertigo, occasionally even resembling that of Meni- 
ere's disease. 

If such pathological sensations continue for a long time the mood and 
character of the patient gradually alter. The so-called "irritable humor" 
develops. Many obnoxiously egoistic individuals met with in daily life are 
in reality examples of psychic neurasthenia. Everything is complained of. 
The individual demands the greatest consideration for his condition; feels 



1124: 



DISEASES OF THE NERVOUS SYSTEM. 



that he has been deeply insulted if his desires are not always immediately 
granted. He may at the same time have but little consideration for others. 
Indeed, in the severer forms of the disease he may show a malicious pleas- 
ure in attempting to make people who seem happier than himself uncom- 
fortable. Such patients complain frequently that they are " misunder- 
stood " by their fellows. 

In many cases the so-called " anxiety conditions " gradually develop; 
one scarcely ever sees a case of advanced neurasthenia without the existence 
of some form of " anxiety." In the simpler forms of anxiety (nosophobic) 
there may be only a fear of impending insanity or of approaching death 
or of apoplexy. More frequently the anxious feeling is localized somewhere 
in the body — in the precordial region, in the head, in the abdomen, in the 
thorax, or more rarely in the extremities. 

In some cases the anxiety becomes intense and the patients are restless, 
and declare that they do not know what to do with themselves. They may 
throw themselves upon a bed, crying and complaining, and making con- 
vulsive movements with the hands and feet. Suicidal tendencies are not 
uncommon in such cases, and patients may in desperation actually take 
their own lives. 

Involuntary mental activity may be very troublesome; the patient com- 
plains that when he is overtired thoughts which he cannot stop or control 
run through his head with lightning-like rapidity. In other cases there is 
marked absence of mind, the individual's mind being so filled up owing 
to the overexcitability of latent memory pictures that he is unable to form 
the proper associations for ideas called up by external stimuli. Sometimes 
a patient complains that a definite word, a name, a number, a melody, or a 
song keeps running in his head in spite of all he can do to abolish it. 

In the severer cases of psychic neurasthenia the so-called " phobias " 
are common. The most frequent form perhaps is agoraphobia, in which 
patients the moment they come into an open space are oppressed by an 
exaggerated feeling of anxiety. They seem " frightened to death," and 
commence to tremble all over; they complain of compression of the thorax 
and palpitation of the heart. They may break into profuse perspiration and 
assert that they feel as though chained to the ground or that they cannot 
move a step. It is remarkable that in some such cases the open space can 
be crossed if the individual be accompanied by some one, even by a child, 
or if he carry a stick or an umbrella! Other people are afraid to be left 
alone (monophobia), especially in a closed compartment (claustrophobia). 

The fear of people and of society is known as anthropophobia. A whole 
series of other phobias have been described — batophobia, or the fear that 
high things will fall; pathophobia, or fear of disease; siderodromophobia, 
or fear of a railway journey; siderophobia or astrophobia, fear of thunder 
and lightning. Occasionally we meet with individuals who are afraid of 
everything and every one-^victims of the so-called pantophobia. 

The special senses may be disturbed, particularly vision. An aching or 
weariness of the eyeballs after reading a few minutes or flashes of light are 
common symptoms. The " irritable eye," the so-called nervous or neu- 
rasthenic asthenopia, is familiar to every family physician. According to 



NEURASTHENIA. 



1125 



Binswanger, the essence of the asthenopia disturbance consists in patho- 
logical sensations of fatigue in the ciliary muscles or the medial recti. 

There may be acoustic disturbances — hyperalgesia and even true hyper- 
acusia. 

One of the most common of all the symptoms of neurasthenia is the 
pressure in the head complained of by these patients. This symptom, vari- 
ously described, may be diffuse, but is more frequently referred to some one 
region — frontal, temporal, parietal, or occipital.* 

When the spinal symptoms predominate — spinal irritation or spinal 
neurasthenia — in addition to many of the features just mentioned, the 
patients complain of weariness on the least exertion, of weakness, pain in 
the back, intercostal neuralgiform pains, and of aching pains in the legs. 
There may be spots of local tenderness on the spine. The rachialgia may 
be spontaneous, or may be noticed only on pressure or movement. Occa- 
sionally there may be disturbances of sensation, particularly a feeling of 
numbness and tingling, and the reflexes may be increased. Visceral neural- 
gias, especially in connection with the genital organs, are frequently met 
with. The aching pain in the back or in the back of the neck is the most 
constant complaint in these cases. In women it is often impossible to say 
whether this condition is one of neurasthenia or hysteria. It is in these 
cases that the disturbances of muscular activity are most pronounced, and 
in the French writings amyosthenia particularly plays an important role. 
The symptoms may be irritative or paretic, or a combination of both. Dis- 
turbances of coordination are not uncommon in the severer forms. These 
are particularly prone to involve the associated movements of the eye mus- 
cles leading to asthenopic lack of accommodation. Drooping of one eyelid 
is very common, probably owing to insufficient innervation on the part of 
the sympathetic rather than to paresis of the nervus oculomotorius. Oc- 
casionally Romberg's symptom may be present, and the patient, or even his 
physician, may fear a beginning tabes. More rarely there is disturbance of 
such finely coordinated acts as writing and articulation, not unlike those 
seen at the onset of general paresis. Such symptoms are always alarming, 
and the greatest care must be taken in establishing a diagnosis. That they 
may be the symptoms of pure neurasthenia, however, can no longer be 
doubted. 

The reflexes in neurasthenia are usually increased, the deep reflexes 
especially never being absent. The condition of the superficial reflexes is 
less constant, though these, too, are usually increased. The pupils are often 
dilated, and the reflexes are usually normal. There may be inequality of the 
pupils in neurasthenia, a point which Pelizaeus has especially emphasized. 

In another type of cases the muscular weakness is extreme, and may go 
on even to complete motor helplessness. Very thorough examination is 
necessary before deciding as to the nature of the affection, since in some 

* For an exhaustive consideration of the mental symptoms of neurasthenia, see the; 
Shattuck Lecture, by Cowles (Boston Medical and Surgical Journal, 1891), as well as two 
German monographs, that of Binswangcr (189G), and that of LSwenfeld. The French 
treatise of Bouveret (1891) is also valuable. F. C. Miiller's llandbuch der Neurasthenia 
(Leipzig, 1893) contains an excellent bibliography of this subject. 



1126 



DISEASES OF THE NERVOUS SYSTEM. 



instances serious mistakes have been made. Here belong the atremia of 
Nef tel, the akinesia algera of Mobius, and the neurasthenic form of astasia 
abasia described by Binswanger. 

In other eases the cardio-vascular symptoms are the most distressing, 
and may occur with only slight disturbance of the cerebro-spinal functions, 
though the conditions are nearly always combined. Palpitation of the heart, 
irregular and very rapid action (neurasthenic tachycardia), and pains and 
oppressive feelings in the cardiac region are the most common symptoms. 
The slightest excitement may be followed by increased action of the heart, 
sometimes associated with sensations of dizziness and anxiety, and the pa- 
tients frequently have the idea that they suffer from serious disease of this 
organ. Attacks of pseudo-angina may occur. 

Vaso-motor disturbances constitute a special feature of many cases. 
Flushes of heat, especially in the head, and transient hyperemia of the 
skin may be very distressing symptoms. Profuse sweating may occur, 
either local or general, and sometimes nocturnal. The pulse may show inter- 
esting features, owing to the extreme relaxation of the peripheral arterioles. 
The arterial throbbing may be everywhere visible, almost as much as in 
aortic insufficiency. The pulse, too, may under these circumstances have 
a somewhat water-hammer quality. The capillary pulse may be seen in 
the nails, on the lips, or on the margins of a line drawn upon the forehead, 
and I have on several occasions seen pulsation in the veins of the back of 
the hand. A characteristic symptom in some cases is the throbbing aorta. 
This " preternatural pulsation in the epigastrium," as Allan Burns calls 
it, may be extremely forcible and suggest the existence of abdominal aneu- 
rism. The subjective sensations associated with it may be very unpleasant, 
particularly when the stomach is empty. 

In women especially, and sometimes in men, the peripheral blood-ves- 
sels are contracted, the extremities are cold, the nose is red or blue, and the 
face has a pinched expression. These patients feel much more comfortable 
when the cutaneous vessels are distended, and resort to various means to 
favor this (wearing of heavy clothing, use of diffusible stimulants). 

The general features of g astro-intestinal neurasthenia have been dealt 
with under the section of nervous dyspepsia. The connection of these cases 
with dilatation of the stomach, floating kidney, and the condition which 
Glenard calls enteroptosis has already been mentioned. 

Sexual neurasthenia is a condition in which there is an irritable weak- 
ness of the sexual organs manifested by nocturnal emissions, unusual de- 
pression after intercourse, and often by a distressing dread of impotence. 
The mental condition of these patients is most pitiable, and they fall an 
easy prey to quacks and charlatans of all kinds. 

Spermatorrhoea is the bugbear of the majority. They complain of con- 
tinued losses, usually without accompanying pleasurable sensations. After 
defecation or micturition there may be seminal discharges. Microscopic ex- 
amination sometimes reveals the presence of spermatozoa. Actual nervous 
impotence is not uncommon. The " painful testicle " is a well-known neu- 
rasthenic phenomenon. 

In the severer cases, especially those bearing the stigmata of degenera- 



NEURASTHENIA. 



1127 



tion, there may be evidence of sexual perversion. The " damnable itera- 
tion" with which writers in our ranks "dish up " this unpleasant subject 
is proof positive that not all prophets speak to edification. 

In females it is common to find a tender ovary, and painful or irregular 
menstruation. 

In all forms of neurasthenia the condition of the urine is important. 
Many cases are complicated with the symptoms of the condition known; 
as lithaemia, and so marked may this be that some have indeed made a spe- 
cial form of lithgemic neurasthenia. Polyuria may be present, but is more 
common in hysteria. With disturbed digestion the urates and oxalates 
may be in excess. 

Diagnosis. — While in the majority of cases the diagnosis can readily 
be made, still there are instances in which it is very difficult. Neurasthenia 
overlaps hypochondria and hysteria on the one hand, and the psychoses and 
degenerative diseases of the nervous system on the other. The term has 
in the past been altogether too loosely used. Simple local disturbances 
and temporary general disturbances the result of sudden overexertion should 
scarcely be diagnosed as neurasthenia. Only when we have before us a 
clinical picture indicating general weakness of the nervous system in addi- 
tion to the local disturbances, no matter how pronounced they are, is the 
diagnosis justifiable. Charcot has designated as neurasthenic stigmata cer- 
tain fundamental and typical symptoms, such as the pain and pressure in 
the head, the disturbances of sleep, the rhachialgia and spinal hyperes- 
thesia, the muscular weakness, the nervous dyspepsia, the disturbances of 
the genital organs, and the typical mental phenomena (irritable humor, 
psychic depression, feelings of anxiety, intellectual fatigue, incapacity of 
decision, and the like). In addition to these cardinal symptoms of the dis- 
ease, he described as secondary or accessory symptoms the feelings of dim- 
ness and vertigo, the neurasthenic asthenopia, the circulatory, respiratory, 
secretory, and nutritive disturbances, disturbances of motility and sensa- 
tion, the fever of neurasthenia, and neurasthenic idiosyncrasies. The anxiety 
conditions and various phobias, as well as the different varieties of tic and 
the occupation neuroses when they accompany neurasthenia, are regarded 
as complications dependent in the majority of instances upon faulty hered- 
ity. I must agree with Binswanger in emphasizing the importance for the 
diagnosis of the peculiar intellectual and emotional condition of the patient, 
as well as the disturbances of sleep. 

Neurasthenia is a disease above all others which has to be diagnosed 
from the subjective statements of the patient, and from an observation of 
his general behavior rather than from the physical examination. The 
physical examination is of the highest importance in excluding other dis- 
eases likely to be confounded with it. That somatic changes occur and thai 
physical signs are often to be made out is very true, and we owe to Lowen- 
feld especially a careful discussion of these points, but there is nothing 
typical or pathognomonic in these objective changes. 

The hypochondriac differs from the neurasthenic in the excessive psychic 
distortion of the pathological sensations to which he is subject. He is 
the victim of actual delusions regarding his condition. 



1123 



DISEASES OF THE NERVOUS SYSTEM. 



The confusion of neurasthenia with hysteria is still more frequent; in 
women especially a diagnosis of hysteria is often made when in reality 
the condition is one of neurasthenia. In the absence of hysterical par- 
oxysms, of crises, and of those marked emotional and intellectual char- 
acteristics of the hysterical individual the diagnosis of hysteria should not 
be made. Of course, in many of the cases of hysteria definite hysterical 
stigmata (hysterical paralyses, convulsions, contractures, anaesthesias, 
alterations in the visual field, etc.) are present, and the diagnosis is not 
difficult. 

Epilepsy is not likely to be confounded with neurasthenia if there be 
definite epileptic attacks, but the cases of petit mal may be puzzling. 

The onset of exophthalmic goitre may be mistaken for neurasthenia, 
especially if there be no exophthalmos at the beginning. The emotional 
disturbances and. the irritability of the heart may mislead the physician. 
In pronounced cases of nervous prostration the differential diagnosis from 
the various psychoses may be extremely difficult. 

The two forms of organic disease of the nervous system with which neu- 
rasthenia is most likely to be confounded are tabes and general paresis. The 
symptoms of the spinal form of neurasthenia may resemble those of the 
former disease, while the symptoms of the psychic or cerebral form of neu- 
rasthenia may be very similar to those of general paresis. The diagnosis, 
as a rule, presents no difficulty if the physician be careful to make a thor- 
ough routine examination. It is only the superficial study of a case that is 
likely to lead one astray. In tabes especially a consideration of the sensory 
disturbances, of the deep reflexes, and of the pupillary findings will always 
establish the presence or absence of the disease. In general paresis there is 
sometimes more difficulty. The onset of general paresis is often character- 
ized by the appearance of symptoms quite like those of ordinary neu- 
rasthenia, and the family physician may entirely overlook the grave nature 
of the malady. The mistake in the other direction is, however, perhaps just 
as common. A physician who once or twice has seen a case of general 
paresis develop out of what appeared to be one of pronounced neurasthenia 
is too prone afterward to suspect every neurasthenic to be developing the 
malign affection. The most marked symptoms, however, of psychic ex- 
haustion do not justify a diagnosis of general paresis even when the his- 
tory is suspicious, unless along with it definite paresis of the facial or mus- 
cles of articulation or of the pupils exist. A history of s}^philis or of chrome 
alcoholism or morphinism associated with severe psychic exhaustion should, 
of course, put one always on his guard, and the physician should be sharply 
on the lookout for the appearance of intellectual defects, paraphasia, facial 
paresis, and sluggishness of the pupils. 

Treatment. — Prophylaxis. — Many patients come under our care a 
generation too late for satisfactory treatment, and it may be impossible to 
restore the exhausted capital. The greatest care should be taken in the 
rearing of children of neuropathic predisposition. From a very early age 
they should be submitted to a process of " psychic hardening," every effort 
being made to strengthen the bodily and mental condition. Even in in- 
fancy the child should not be pampered. Later on the greatest care should 



NEURASTHENIA. 



1129 



be exercised with regard to food, sleep, and school work. Complaints of 
children should not be too seriously considered. 

Much depends upon the example set by the parents. A restless, emo- 
tional, constantly complaining mother will rack the nervous system of a 
delicate child. In some instances, for the welfare of a developing boy or 
girl, the physician may find it necessary to advise its removal from 
home. 

Neurotic children are especially liable during development to fits of 
temper and of emotional disturbance. These should not be too lightly 
considered. Above all, violent chastisement in such cases is to be avoided, 
and loss of temper on the part of the parent or teacher is particularly per- 
nicious for the nervous system of the child. Where possible, in such in- 
stances, the best treatment is to put the obstreperous child immediately to 
bed, and if the excitement and temper continue a warm bath followed by 
a cool douch may be effective. If he be put to bed after the bath sleep soon 
follows. 

Special attention is necessary at puberty in both boys and girls. If 
there be at this period any marked tendency to emotional disturbance or to 
intellectual weakness the child should be removed from school and every 
care taken to avoid unfavorable influences. 

Personal Hygiene. — Throughout life individuals of neuropathic predis- 
position should obey scrupulously certain hygienic and prophylactic rules. 
Intellectual work especially should be judiciously limited and should alter- 
nate frequently with periods of repose. Excitement of all kinds should of 
course be avoided, and such individuals will do well to be abstemious in 
the use of tobacco, tea, coffee, and alcohol, if, indeed, they be permitted to 
use these substances at all. The habit, happily in this country becoming 
very common, of taking at least once a year a prolonged holiday away from 
the ordinary environment, in the woods, in the mountains, or at the sea- 
shore, should be urgently enjoined upon every neuropathic individual. In 
many instances it is found to be the greatest relief and rest if the patient 
can take his holiday away from his relatives. 

During ordinary life nervous people should, during some portion of 
each day, pay rational attention to the body. Cold baths, swimming, exer- 
cises in the gymnasium, gardening, golf, lawn tennis, cricket, hunting, 
shooting, rowing, sailing, and bicycling are of value in maintaining the 
general nutrition. Such exercises are, of course, to be recommended only 
to individuals physically equal to them. If neurasthenia be once well de- 
veloped the greatest care must be observed in the ordering of exercise. 
Many nervous girls have been completely broken down by following injudi- 
cious advice with regard to long walks. 

Treatment of the Condition. — The treatment of neurasthenia when once 
established presents a varied problem to the thoughtful physician. Every 
case must be handled upon its own merits, no two, as a rule, requiring ex- 
actly the same methods. In general it will be the aim of (he medical 
adviser to remove the patient as far as possible from the influences which 
have led to his downfall, and to restore to normal the nervous mechanisms 
which have been weakened by injurious influences. The general character 



1130 



DISEASES OF THE NERVOUS SYSTEM. 



of the individual, his physical and social status must of course be consid- 
ered, and the therapeutic measures carefully adjusted to these. 

Above all, the physician must first gain the confidence of. his patient, 
and this he will not do if he be inattentive to the complaints of the individ- 
ual, especially at first, or if he rudely tell the patient before he has care- 
fully examined him and observed him for some time that his troubles are 
imaginary. As has been said, it is education more than medicine that 
these patients need, but the patients themselves do not wish to be educated; 
they come to the physician to be treated, and the educating process has to 
be disguised. 

The diagnosis having been settled, the physician may assure the patient 
that with prolonged treatment, during which his cooperation with the physi- 
cian is absolutely essential, he may expect to get well. He must be told 
that much depends upon himself and that he must make a vigorous 
effort to overcome certain of his tendencies, and that all his strength 
of will will be needed to further the progress of the cure. In the case of 
business or professional men, in whom the condition develops as a result 
of overwork or overstudy, it may be sufficient to enjoin absolute rest with 
change of scene and diet. A trip abroad, with a residence for a month or 
two in Switzerland, or, if there are symptoms of nervous dyspepsia, a resi- 
dence at one of the Spas will usually prove sufficient. The excitement of 
the large cities abroad should be avoided. The longer the disease has 
lasted and the more intense the symptoms have been, the longer the time 
necessary for the restoration of health. In cases of any severity the patient 
must be told that at least six months' complete absence from business, under 
strict medical guidance, will be necessary. Shorter periods may of course 
be of benefit, which, however, as a rule, will be only temporary. 

It will be wise in very many cases to treat the individual for a few 
weeks at least in a hospital or other institution before sending him away on 
a journey. In this preliminary treatment the greatest tact is required on 
the part of the medical attendant and nurse. The patient should not see 
the doctor too often after the first careful examination, although he should 
of course receive regular visits from him. The physician will make a mis- 
take if he responds to frequent calls on the part of the patient between- 
the periods of his regular visits. The choice of a nurse is by no means an 
easy matter. That she should be healthy, strong, and by no means 
nervous herself are among the first considerations. Sallow-faced, emo- 
tional, emaciated women can only do harm if detailed to the care of a 
nervous patient. 

It will often be found advisable to make out a daily programme, which 
shall occupy almost the whole time of the patient. At first he need know 
nothing about this, the case being given over entirely to the nurse. As 
improvement advances, moderate physical and intellectual exercises, alter- 
nating frequently with rest and the administration of food, may be under- 
taken. Some one hour of the day may be left free for reading, correspond- 
ence, conversation, and games." In some instances the writing of letters is 
particularly harmful to the patient and must be prohibited or limited. Cul- 
tured individuals may find benefit from attention to drawing, painting, mod- 



NEURASTHENIA. 



1131 



elling, translating from a foreign language, the making of abstracts, etc., 
for short periods in the day. 

In not a few cases, including a large proportion of neurasthenic women, 
a systematic Weir Mitchell treatment rigidly carried out should be tried 
(see Hysteria). For obstinate and protracted cases, particularly if com- 
bined with the chloral or morphia habit, no other plan is so satisfactory. 
The patient must be isolated from his friends, and any regulations under- 
taken must be strictly adhered to, the consent of the patient and his family 
having first been gained. If the case responds well to the treatment there 
should be a gain of from 2 to 4 pounds per week. The benefit is often 
extraordinary, individuals increasing in weight as much as from 50 to 80 
pounds in the course of twelve weeks. The treatment of the gastric and in- 
testinal symptoms so important in this condition has already been con- 
sidered. For the irregular pains, particularly in the back and neck, the 
thermo-cautery is invaluable. 

Hydrotherapy is indicated in nearly every case if it can be properly 
applied. Much can be done at home or in an ordinary hospital, but for 
systematic hydrotherapeutic treatment residence in a suitable sanitarium is 
necessary. I have found the wet pack of especial value. Particularly at 
night in cases of sleeplessness it is perhaps the best remedy against in- 
somnia we have. Some patients gain rapidly in weight through the sys- 
tematic use of the wet pack. Salt baths are more helpful to some patients. 
The various forms of douches, partial packs, foot baths, etc., may be valu- 
able in individual cases. The Scotch douche is often invigorating in the 
milder cases. 

Electrotherapy is of some value, though only in combination with psy- 
chic treatment and hydrotherapy. General and local faradization, galvanic 
electricity, and Franklinization may be used; in every case, however, with 
great caution and only by skilled operators. 

Treatment by drugs should be avoided as much as possible. They are 
of benefit chiefly in the combating of single symptoms. A placebo is 
sometimes necessary for its psychic effect. Alcohol, morphia, chloral, or co- 
caine should never be given. The family physician is often responsible for 
the development of a drug habit. I have been repeatedly shocked by the 
loose, careless way in which physicians inject morphia for a simple head- 
ache or a mild neuralgia. 

General tonics may be helpful, especially if the individual be anamiic. 
Arsenic and more often iron are then indicated. The value of phosphorus 
has been exaggerated. For the severer pains and nervous attacks some 
sedative may occasionally be necessary, especially at the beginning of the 
treatment. The bromides, especially a mixture of the salts of ammonium, 
potassium, and sodium may here be given with advantage. An occasional 
dose of phenacetin, antipyrin, or salipyrin may be required, but the less of 
these substances we can get along with the better. For the relief of sleep- 
lessness all possible measures should be resorted to before the employment of 
drugs. The wet pack will usually suffice. If absolutely necessary to give 
a drug, sulphonal, trional, or amylene hydrate may be employed. 

In cases in which the anxiety conditions are disturbing, the cautious use 



1132 



DISEASES OF THE NERVOUS SYSTEM. 



of opium in pill form may be necessary, since, as in the psychoses, opium 
here will sometimes yield permanent relief. A prolonged treatment with 
opium is, however, never necessary in neurasthenia. 

XIII. THE TRAUMATIC NEUROSES 

{Railway Brain and Railway Spine; Traumatic Hysteria). 

Definition. — A morbid condition following shock which presents the 
symptoms of neurasthenia or hysteria or of both. The condition is known 
as " railway brain " and " railway spine." 

Erichsen regarded the condition as the result of inflammation of the 
meninges and cord, and gave it the name railway spine. Walton and 
J. J. Putnam, of Boston, were the first to recognize the hysterical nature 
of many of the cases, and to WestphaFs pupils we owe the name traumatic 
neurosis. For an excellent discussion of the whole question the reader is 
referred to Pearce Baily's recent work, On Accident and Injury; their Kela- 
tion to Diseases of the Nervous System. 

Etiology. — The condition follows an accident, often in a railway 
train, in which injury has been sustained, or succeeds a shock or concus- 
sion, from which the patient may apparently not have suffered in his body. 
A man may appear perfectly well for several days, or even a week or 
more, and then develop the symptoms of the neurosis. Bodily shock or 
concussion is not necessary. The affection may follow a profound mental 
impression; thus, an engine-driver ran over a child, and received thereby 
a very severe shock, subsequent to which the most pronounced symptoms 
of neurasthenia developed. Severe mental strain combined with bodily 
exposure may cause it, as in a case of a naval officer who was wrecked in 
a violent storm and exposed for more than a day in the rigging before 
he was rescued. A slight blow, a fall from a carriage or on the stairs may 
suffice. 

Symptoms. — The cases may be divided into three groups: simple 
neurasthenia, cases with marked hysterical manifestations, and cases with 
severe symptoms indicating or simulating organic disease. 

(a) Simple Traumatic Neurasthenia. — The first symptoms usually de- 
velop a few weeks after the accident, which may or may not have been 
associated with an actual trauma. The patient complains of headache 
and tired feelings. He is sleepless and finds himself unable to concentrate 
his attention properly upon his work. A condition of nervous irritability 
develops, which may have a host of trivial manifestations, and the entire 
mental attitude of the person may for a time be changed. He dwells con- 
stantly upon his condition, gets very despondent and low-spirited, and in 
extreme cases melancholia may develop. He may complain of numbness 
and tingling in the extremities, and in some cases of much pain in the 
back. The bodily functions may be well performed, though such patients 
usually have, for a time at least, disturbed digestion and loss in weight. 
The physical examination may be entirely negative. The reflexes are 
slightly increased, as in ordinary neurasthenia. The pupils may be un- 



THE TRAUMATIC NEUROSES. 



1133 



equal; the cardio-vascular changes already described in neurasthenia may 
be present in a marked degree. According as the symptoms are more 
spinal or more cerebral, the condition is known as railway brain or rail- 
way spine. 

(2) Cases with Marked Hysterical Features. — Following an injury of 
any sort, neurasthenic symptoms, like those described above, may develop, 
and in addition symptoms regarded as characteristic of hysteria. The 
emotional element is prominent, and there is but slight control over the 
feelings. The patients have headache, backache, and vertigo. A violent 
tremor may be present, and indeed constitutes the most striking feature of 
the case. I have recently seen an engineer who developed subsequent to 
an accident a series of nervous phenomena, but the most marked feature 
was an excessive tremor of the entire body, which was specially manifest 
during emotional excitement. The most pronounced hysterical symptoms 
are the sensory disturbances. As first noted by Putnam and Walton, hemi- 
anesthesia may occur as a sequence of traumatism. This is a common 
symptom in France, but rare in England and in this country. Achromatop- 
sia may exist on the anaesthetic side. A second, more common, manifesta- 
tion is limitation of the field of vision, similar to that which occurs in 
hysteria. 

Eemarkable disturbances may develop in some of these cases. A few 
months ago I saw a man who had been struck by an electric car, whose 
chief symptom was an extraordinary increase in the number of respira- 
tions. He was a stout, powerfully built man, and presented practically no 
other symptom than dyspnoea of the most extreme grade. At the time of 
observation his respirations were over 130 per minute, and he stated that 
they had been counted at over 150. 

(3) Cases in which the Symptoms suggest Organic Disease of the Brain 
and Cord. — As a result of spinal concussion, without fracture or external 
injury, there may subsequently develop symptoms suggestive of organic 
disease, which may come on rapidly or at a late date. In a case reported by 
Leyden the symptoms following the concussion were at first slight and the 
patient was regarded as a simulator, but finally the condition became aggra- 
vated and death resulted. The post mortem showed a chronic pachy- 
meningitis, which had doubtless resulted from the accident. The cases 
in this group about which there is so much discussion are those which dis- 
play marked sensory and motor changes. Following an accident in which 
the patient has not received external injury a condition of excitement may 
develop within a week or ten days; he complains of headache and backache, 
and on examination sensory disturbances are found, either hemianesthesia 
or areas on the skin in which the sensation is much benumbed; or painful 
and tactile impressions may be distinctly felt in certain regions, and the 
temperature sense is absent. The distribution may be bilateral and sym- 
metrical in limited regions or hemiplegic in type. Limitation of the field 
of vision is usually marked in these cases, and there may be disturbance 
of the senses of taste and smell. The superficial reflexes may be diminished; 
usually the deep reflexes are exaggerated. The pupils may be unequal: the 
motor disturbances are variable. The French writers describe cases of 



1134 



DISEASES OF THE NERVOUS SYSTEM. 



monoplegia with or without contracture, symptoms upon which Charcot lays 
great stress as a manifestation of profound hysteria. The combination of 
sensory disturbances — anaesthesia or hyperesthesia — with paralysis, particu- 
larly if monoplegia and the occurrence of contractures without atrophy and 
with normal electrical reactions, may be regarded as distinctive of hysteria. 

In rare cases following trauma and succeeding to symptoms which may 
have been regarded as neurasthenic or hysterical, there are organic changes 
which may prove fatal. That this sequence occurs is demonstrated clearly 
by recent post-mortem examinations. The features upon which the greatest 
reliance can be placed as indicating organic change are optic atrophy, blad- 
der symptoms, particularly in combination with tremor, paresis, and exag- 
gerated reflexes. 

The anatomical changes in this condition have not been very definite. 
When death follows spinal concussion within a few days there may be no 
apparent lesion, but in some instances the brain or cord has shown punc- 
tiform haemorrhages. Edes has reported 4 cases in which a gradual degen- 
eration in the pyramidal tracts followed concussion or injury of the spine; 
but in all these cases there was marked tremor and the spinal symptoms 
developed early or followed immediately upon the accident. Autopsies 
upon cases in which organic lesions have supervened upon a traumatic 
neurosis are extremely rare. Bernhardt reports an instance of a man, aged 
thirty-three, who in 1886 received a kick from a horse on the epigastrium 
and subsequently developed the symptom-complex of neurasthenia and hys- 
teria with attacks of vertigo and great psychical depression. He afterward 
had more marked mental symptoms and attacks of unconsciousness. He 
committed suicide and the brain and cord showed a beginning multiple 
sclerosis in the white matter, which was possibly associated with an ad- 
vanced grade of arterio-sclerosis. In a second case a man, aged forty-two, 
received a shock in a railway accident in July, 1884. He was rendered 
unconscious and had a slight injury in the buttock region. In a few weeks 
symptoms of traumatic neurosis developed, particularly great depression 
of spirits, with headache and sensory disturbances in the feet and hands. 
Tremor and great weakness were complained of when he attempted to 
work. There was no increase in the reflexes. The case was regarded as an 
instance of simulation and a defect in objective symptoms favored this 
view. Subsequently this judgment was reversed, but he did not improve. 
He died in January, 1889, with symptoms of cardiac dyspnoea. Macro- 
scopically the brain and cord appeared normal. There was extreme arterio- 
sclerosis, particularly of the vessels of the brain and cord. In the latter 
there were scattered areas of degeneration in the white substance, and de- 
generation in the sympathetic ganglia. 

I have entered somewhat fully into this question because of its extreme 
importance and on account of the paucity of the observations upon cases 
which have subsequently developed symptoms of organic disease. Exam- 
ples of it are extremely rare. ■ So far as I know no case with autopsy has 
been reported in this country, nor have I seen an instance in which the 
clinical features pointed to an organic disease which had followed upon a 
traumatic neurosis. 



THE TRAUMATIC NEUROSES. 



1135 



Diagnosis. — A condition of fright and excitement following an acci- 
dent may persist for days or even weeks, and then gradually pass away. 
The symptoms of neurasthenia or of hysteria which subsequently develop 
present nothing peculiar and are identical with those which occur under 
other circumstances. Care must be taken to recognize simulation, and, as in 
these cases the condition is largely subjective, this is sometimes extremely 
difficult. In a careful examination a simulator will often reveal himself 
by exaggeration of certain symptoms, particularly sensitiveness of the spine, 
and by increasing voluntarily the reflexes. Maunkopff suggests as a good 
test to take the pulse-rate before, during, and after pressure upon an area 
said to be painful. If the rate is quickened, it is held to be proof that the 
pain is real. This is not, however, always the case. It may require a careful 
study of the case to determine whether the individual is honestly suffering 
from the symptoms of which he complains. A still more important ques- 
tion in these cases is, Has the patient organic disease ? The symptoms given 
under the first two groups of cases may exist in a marked degree and may 
persist for several years without the slightest evidence of organic change. 
Hemianesthesia, limitation of the field of vision, monoplegia with con- 
tracture, may all be present as hysterical manifestations, from which recov- 
ery may be complete. In our present knowledge the diagnosis of an organic 
lesion should be limited to those cases in which optic atrophy, bladder 
troubles, and signs of sclerosis of the cord are well marked — indications 
either of degeneration of the lateral columns or of multiple sclerosis. 

Prognosis. — A majority of patients with traumatic hysteria recover. 
In railway cases, so long as litigation is pending and the patient is in the 
hands of lawyers the symptoms usually persist. Settlement is often the 
starting-point of a speedy and perfect recovery. I have known return to 
health after the persistence of the most aggravated symptoms with com- 
plete disability of from three to five years' duration. On the other hand, 
there are a few cases in which the symptoms persist even after the litigation 
has been closed; the patient goes from bad to worse and psychoses develop, 
such as melancholia, dementia, or occasionally progressive paresis. And, 
lastly, in extremely rare cases, organic lesions may develop as a sequence 
of the traumatic neurosis. 

The function of the physician acting as medical expert in these cases 
consists in determining (a) the existence of actual disease, and (b) its char- 
acter, whether simple neurasthenia, severe hysteria, or an organic lesion. 
The outlook for ultimate recovery is good except in cases which present the 
more serious symptoms above mentioned. Nevertheless, it must be borne 
in mind that traumatic hysteria is one of the most intractable affections 
which we are called upon to treat. In the treatment of the traumatic 
neuroses the practitioner may be guided by the principles laid down in the 
preceding chapter, in which the treatment of neurasthenia in general has 
been described. 



1136 



DISEASES OF THE NERVOUS SYSTEM. 



XIV. OTHER FORMS OF FUNCTIONAL PARALYSIS. 

I. Periodical Paralysis. 

The periodical paralysis of the ocular muscles^ which may recur for 
years, has already been referred to. A periodical paralysis involving the 
general muscles, also a " family " affection, may return with great regu- 
larity. Goldflam described twelve cases in one family, the heredity being 
through the mother. In this country E. W. Taylor described eleven cases 
in one family in five generations. 

The clinical picture is similar in all recorded cases. The paralyis in- 
volves, as a rule, the arms and legs, but may be general below the neck. 
It comes on in healthy persons without apparent cause, and often during 
sleep. At first there may be weakness of the limbs, a feeling of weariness 
and sleepiness, but rarely sensory symptoms. The paralysis, beginning in 
the legs, to which it may be confined, is usually complete within the first 
twenty-four hours. The neck muscles are sometimes involved, and occa- 
sionally those of the tongue and pharynx. The cerebral nerves and the 
special senses are, as a rule, unaffected. The temperature is normal or 
subnormal and the pulse slow. The deep reflexes are diminished, sometimes 
abolished, and the skin reflexes may be enfeebled. A most remarkable 
feature is the extraordinary reduction or complete abolition of the faradic 
excitability both of muscles and of nerves. 

Improvement begins within a few hours or a day or two, the paralysis 
disappearing completely and the patient becoming perfectly well. The 
attacks usually recur at intervals of one to two weeks, but they may return 
daily. They generally cease after the fiftieth year. There may be signs 
of acute dilatation of the heart during the attack. In the three cases 
reported by J. K. Mitchell, Flexner, and Edsall, a diminished kreatinin 
excretion for several days before and at the beginning of a seizure was re- 
peatedly found. There was a rise to normal after the attacks. Potassium 
citrate in full doses either shortened or aborted the paralyses. 

II. Astasia; Abasia. 

These terms, indicating respectively inability to stand and inability to 
walk, have been applied by Charcot and Bloeq to diseased conditions char- 
acterized by loss of the power of standing or of walking, with retention of 
muscular power, coordination, and sensation. Blocq's definition is as fol- 
lows: "A morbid state in which the impossibility of standing erect and 
walking normally is in contrast with the integrity of sensation, of muscu- 
lar strength, and of the coordination of the other movements of the lower 
extremities." The condition forms a symptom group, not a morbid entit} 7 , 
and is probably a functional neurosis. Knapp in his monograph analyzes 
the 50 cases reported in the literature. Twenty-five of these were in men, 
25 in women. In 21 cases hysteria was present; in 3, chorea; in 2, epi- 
lepsy; and in 4, intention psychoses. As a rule, the patients, though able 
to move the feet and legs perfectly when in bed, are either unable to walk 
properly or cannot stand at all. The disturbances have been very varied, 



RAYNAUD'S DISEASE. 



1137 



and different forms have been recognized. The commonest, according to 
Knapp's analysis of the recorded cases, is the paralytic, in which the legs 
give out as the patient attempts to walk and " bend under him as if made 
of cotton." " There is no rigidity, no spasm, no incoordination. In bed, 
sitting, or even while suspended, the muscular strength is found to be good." 
Other cases are associated with spasm or ataxia; thus there may be move- 
ments which stiffen the legs and give to the gait a somewhat spastic char- 
acter. In other instances there are sudden flexions of the legs, or even of 
the arms, or a saltatory, spring-like spasm. In a majority of the cases <it 
is a manifestation of a neurosis allied to hysteria. 

The cases, as a rule, recover, particularly in young persons. Relapses 
are not uncommon. The rest treatment and static electricity should be 
employed. 

Till. VASO-MOTOR AND TEOPHIC DISORDERS. 
I. RAYNAUD'S DISEASE. 

Definition. — A vascular disorder, probably dependent upon vaso- 
motor influences, characterized by three grades of intensity: (a) Local syn- 
cope, (b) local asphyxia, and (c) local or symmetrical gangrene. 

Local Syncope. — This condition is seen most frequently in the extremi- 
ties, producing the condition known as dead fingers or dead toes. It is 
analogous to that produced by great cold. The entire hand may be affected 
with the fingers; more commonly only one or more of the ringers. This 
feature of the disease rarely occurs alone, but is generally associated with 
local asphyxia. The common sequence is as follows: On exposure to slight 
cold or in consequence of some emotional disturbance the fingers become 
white and cold, or both fingers and toes are affected. The pallor may con- 
tinue for an indefinite time, though usually not more than an hour or so; 
then gradually a reaction follows and the fingers get burning hot and red. 
This does not necessarily occur in all the fingers together; one finger may 
be as white as marble, while the adjacent ones are of a deep red or plum 
color. 

Local Asphyxia. — Chilblains form the mildest grade of this condition. 
It usually follows the local syncope, but it may come on independently. 
The fingers and toes are oftenest affected, next in order the ears; more 
rarely portions of the skin on the arms and legs. During an attack the 
fingers alone, sometimes the hands, also swell and become intensely con- 
gested. In the most extreme grade the fingers are perfectly livid, and the 
capillary circulation is almost stagnant. The swelling causes stiffness and 
usually pain, not acute, but due to the tension and distention of the skin. 
Sometimes there is marked anaesthesia. Pain of a most excruciating kind 
may be present. Attacks of this sort may recur for years, and be brought 
on by the slightest exposure to cold or in consequence of disturbances, eith< r 
mental or, in some instances, gastric. Apart from this unpleasant symp- 
71 



1138 



DISEASES OF THE NERVOUS SYSTEM. 



torn the general health may be very good. The condition is always worse 
during the winter, and may be present only when the external temperature 
is low. 

Local or Symmetrical Gangrene. — The mildest grade of this condition 
follows the local asphyxia, in the chronic cases of which small necrotic 
areas are sometimes seen at the tips of the fingers. Sometimes the pads 
of the fingers and of the toes are quite cicatricial from repeated slight losses 
of this kind. So also when the ears are affected there may be superficial 
loss of substance at the edge. The severer cases, which terminate in ex- 
tensive gangrene, are fortunately rare. 

In an attack the local asphyxia persists in the fingers. The terminal 
phalanges, or perhaps the end of only one finger, become black, cold, and in- 
sensible. The skin begins to necrose and superficial gangrenous blebs appear. 
Gradually a line of demarkation shows itself and a portion of one or more of 
the firigers sloughs away. The resulting loss of substance is much less than 
the appearance of the hand or foot would indicate, and a condition which 
looks as if the patient would lose all the fingers or half of a foot may result 
perhaps in only a slight superficial loss in the phalanges. In severer cases 
the greater portion of a finger or the tip of the nose may be lost. Occa- 
sionally the disease is not confined to the extremities, but affects sym- 
metrical patches on the limbs or trunk, and may pass on to rapid gangrene. 
These severe types of cases occur particularly in young children, and death 
may result within three or four days. The attacks are usually very pain- 
ful, and the motion of the part is much impaired. In some cases numbness 
and tingling persist for a long time. 

The climax of this series of neuro-vascular changes is seen in the re- 
markable instances of extensive multiple gangrene. They are most com- 
mon ;n children, and may progress with frightful rapidity. In the Medico- 
Chirurgical Society's Transactions, vol. xxii, there is an extraordinary case 
reported, in which the child, aged three, lost in this way both arms above 
the elbow, and the left leg below the knee. There also had been a spot 
of local gangrene on the nose. Spontaneous amputation occurred, and the 
child made a complete recovery. The cases are more frequent than has 
been supposed, and an illustration is given by Weeks, of Marion, Ohio, in 
which the boy had rheumatic pains in the legs, and purpuric blotches de- 
veloped before the gangrene began (Medico-Surgical Bulletin, July 1, 
1894). 

There are remarkable concomitant symptoms in Eaynaud's disease to 
which a good deal of attention has been paid of late years. Hemoglobi- 
nuria may develop during an attack, or may take the place of an outbreak. 
In such instances the affection is usually brought on by cold weather. In 
a case reported by H. M. Thomas from my clinic, Raynaud's disease occurred 
for three successive winters and always in association with hemoglobinuria. 
The attacks were sometimes preceded by a chill. Several cases of the kind 
are found in Barlow's appendix to his translation of Eaynaud's paper for 
the New Sydenham Society. The onset with a chill, as in the case just 
mentioned, has doubtless given rise to the idea that the disease is in some 
way associated with ague. Cerebral symptoms, particularly mental torpor 



ERYTHROMELALGrlA. 



1139 



and transient loss of consciousness, have also been noticed in some cases. 
The case just mentioned with hemoglobinuria had epilepsy with the at- 
tacks. Exposure on a cold day would bring on an epileptic seizure with 
the local asphyxia and bloody urine. Another patient, the subject for years, 
of Kaynaud's disease, has had many attacks of transient hemiplegia on one 
side or the other, when on the right side with aphasia. Since the second 
edition of this work was issued she died in an attack. Occasionally joint 
affections develop, particularly anchylosis and thickening of the phalan- 
geal articulations. Southey has reported a case in which mania developed, 
and Barlow an instance in which the woman had delusions. Peripheral 
neuritis has been found in several cases. 

The pathology of this remarkable disease is still obscure. Eaynaud 
suggested that the local syncope was produced by contraction of the vessels, 
which seems likely. The asphyxia is dependent upon dilatation of the. 
capillaries and small veins, probably with the persistence of some degree 
of spasm of the smaller arteries. There are two totally different forms of 
congestion, which may be shown in adjacent fingers; one may be swollen, 
of a vivid red color, extremely hot, the capillaries and all the vessels fully 
distended, and the ansemia produced by pressure may be instantaneously 
obliterated; the adjacent finger may be equally swollen, absolutely cyanotic, 
stone cold, and the anaemia produced by pressure takes a long time to 
disappear. In the latter case the arterioles are probably still in a condition 
of spasm. Monro's monograph may be consulted for additional details. 

Treatment. — In many cases the attacks recur for years uninfluenced 
by treatment. Mild attacks require no treatment. In the severer forms 
of local asphyxia, if in the feet, the patient should be kept in bed with the 
legs elevated. The toes should be wrapped in cotton-wool. The pain is 
often very intense and may require morphia. Carefully applied, systematic 
massage of the extremities is sometimes of benefit. Galvanism may be tried. 
Barlow advises immersing the affected limb in salt water and placing one 
electrode over the spine and the other in the water. Nitroglycerin has been 
warmly recommended by Cates. 



II. ERYTHROMELALGIA (Red Neuralgia). 

Definition. — " A chronic disease in which a part or parts — usually one 
or more extremities — suffer with pain, flushing, and local fever, made far 
worse if the parts hang down " (Weir Mitchell). The name signifies a pain- 
ful, red extremity. 

Symptoms.— In 1872 (Phila. Med. Times, November 23d), in a lec- 
ture on certain painful affections of the feet, Weir Mitchell described the 
case of a sailor, aged forty, who after an African fever began to have " dull, 
heavy pains, at first in the left and soon after in the right foot. There was 
no swelling at first. When at rest he was comfortable and the feet were 
not painful. After walking the feet were swollen. They scarcely pitted 
on pressure, but were purple with congestion; the veins were everywhere 
singularly enlarged, and the arteries were throbbing visibly. The whole 



1140 



DISEASES OF THE NERVOUS SYSTEM. 



foot was said to be aching and burning, but above the ankle there was 
neither swelling, pain, nor, flushing." As the weather grew cool he got 
relief. Nothing seemed to benefit him. This brief summary of Mitchell's 
first case gives an accurate clinical picture of the disease. His second com- 
munication, On a Eare Vaso-motor Neurosis of the Extremities, appeared 
in the Am. Jour, of the Medical Sciences for July, 1878, while in his Clin- 
ical Lessons on Nervous Diseases, 1897, will be found additional observa- 
tions. 

The disease is rare. Eost states that there are only about 40 instances in 
the literature. The feet are much more often affected than the hands. The 
pain may be of the most atrocious character. It is usually, but not always, 
relieved by cool weather; in one of my cases the winter aggravates the trou- 
ble. In a few cases (Eisner, Dehio, Eolleston) the affection has been com- 
plicated with Eaynaud's disease. 

Mitchell speaks of it as a " painful nerve-end neuritis." Dehio suggests 
that there may be irritation in the cells of the ventral horns of the cord 
at certain levels. Excision of the nerves passing to the parts has been fol- 
lowed by relief. In one of Mitchell's cases gangrene of the foot followed 
excision of four inches of the musculo-cutaneous nerve and stretching of the 
posterior tibial. Sclerosis of the arteries was found. 



ill. ANGIO-NEUROTIC CEDEMA. 

Definition. — An affection characterized by the occurrence of local 
cedematous swellings, more or less limited in extent, and of transient dura- 
tion. Severe colic is sometimes associated with the outbreak. There is a 
marked hereditary disposition in the disease. 

Symptoms. — The oedema appears suddenly and is usually circum- 
scribed. It may appear in the face; the eyelid is a common situation; or 
it may involve the lips or cheek. The backs of the hands, the legs, or the 
throat may be attacked. Usually the condition is transient, associated per- 
haps with slight gastro-intestinal distress, and the affection is of little 
moment. There may be a remarkable periodicity in the outbreak of the 
oedema. In Matas' case this periodicity was very striking; the attack came 
on every day at eleven or twelve o'clock. The disease may be hereditary 
through many generations. In the family whose history I reported, five 
generations had been affected, including twenty-two members. The swell- 
ings appear in various parts; only rarely are they constant in one locality. 
The hands, face, and genitalia are the parts most frequently affected. Itch- 
ing, heat, redness, or in some instances, urticaria may precede the out- 
break. Sudden oedema of the larynx may prove fatal. Two members of 
the family just referred to died of this complication. In one member of this 
family, whom I saw repeatedly in attacks, the swellings came on in different 
parts; for example, the under lip would be swollen to such a degree that 
the mouth could not be opened. The hands enlarge suddenly, so that the 
fingers cannot be bent. The attacks recur every three or four weeks. Ac- 
companying them are usually gastro-intestinal attacks, severe colic, pain ; 



FACIAL HEMIATROPHY. 



1141 



nausea, and sometimes vomiting. It is quite possible that some of the cases 
of Leydems intermittent vomiting may belong to this group. The colic 
is of great intensity and usually requires morphia. Arthritis apparently 
does not occur. Periodic attacks of cardialgia have also been met with dur- 
ing the outbreak of the oedema. Hemoglobinuria has occurred in several 
cases. 

The disease has affinities with urticaria, the giant form of which is 
probably the same disease. There is a form of severe purpura, often with 
urticarial manifestations, which is also associated with marked gastro- 
intestinal crises, and it is interesting to note that Schlesinger has reported 
a case in which a combination of erythromelalgia, Eaynaud's disease, and 
acute oedema occurred. Quincke regards the condition as a vaso-motor 
neurosis, under the influence of which the permeability of the vessels is 
suddenly increased. Milroy, of Omaha, has described cases of hereditary 
oedema, twenty-two individuals in six generations, in which there existed 
from birth a solid oedema of one or of both legs, without any special incon- 
venience or any progressive increase of the disease. 

Some years ago I described a remarkable vaso-motor neurosis charac- 
terized by swelling and tumefaction of the whole arm on exertion. My patient 
was a man, healthy in every other respect. A similar case has been ob- 
served in Philadelphia; on the supposition that it might be due to pressure, 
the axillary vessels were exposed, but nothing was found. 

The treatment is very unsatisfactory. In the cases associated with anae- 
mia and general nervousness, tonics, particularly large doses of strychnia, 
do good; but too often the disease resists all treatment. I have seen great 
improvement follow the prolonged use of nitroglycerin. 



IV. FACIAL HEMIATROPHY. 

An affection characterized by progressive wasting of the bones and soft 
tissues of one side of the face. The atrophy starts in childhood, but in a 
few cases has not come on until adult life. Perhaps after a trifling injury 
or disease the process begins, either diffusely or more commonly at one spot 
on the skin. It gradually spreads, involving the fat, then the bones, more 
particularly the upper jaw, and last and least the muscles. The wasting 
is sharply limited at the middle line, and the appearance of the patient is 
very remarkable, the face looking as if made up of two halves from differ- 
ent persons. There is usually change in the color of the skin and the hair 
falls. Owing to the wasting of the alveolar processes the teeth become loose 
and ultimately drop out. The eye on the affected side is sunken, owing to 
loss of orbital fat. There is usually hemiatrophy of the tongue on the same 
side. Disturbance of sensation and muscle twitching may precede or ac- 
company the atrophy. In a majority of the cases the atrophy has been 
confined to one side of the face, but there arc instances on record in which 
the disease was bilateral, and a few cases in which there were areas of atro- 
phy on the back and on the arm of the same side, The disease is rare; only 
about 100 cases are in the literature (Mobins). 



1142 



DISEASES OF THE NERVOUS SYSTEM. 



Of the autopsies, Mendel's alone is satisfactory. There was the terminal 
stage of an interstitial neuritis in all the branches of the trigeminus, from 
its origin to the periphery, most marked in the superior maxillary branch. 

The disease is recognized at a glance. The facial asymmetry associated 
with congenital wryneck must not be confounded with progressive facial 
hemiatrophy. Other conditions to be distinguished are: Facial atrophy 
in anterior polio-myelitis, and more rarely in the hemiplegia of infants and 
adults; the atrophy following nuclear lesions and sympathetic nerve paraly- 
sis; acquired facial hemihypertrophy, such as in the case recorded by D. 
W. Montgomery, which may by contrast give to the other side an atrophic 
appearance; and, lastly, scleroderma (a closely related affection), if confined 
to one side of the face. The precise nature of the disease is still doubtful, 
but it is a suggestive fact that in many of the cases the atrophy has followed 
the acute infections. It is incurable. 



V. ACROMEGALY. 

Definition. — A dystrophy characterized by abnormal processes of 
growth, chiefly in the bones of the face and extremities. 

The term was introduced by Marie, and signifies large extremities. 

Etiology. — It occurs rather more frequently in women. The affection 
usually begins about the twenty-fifth year, though in some instances as late 
as the fortieth. Eheumatism, syphilis, and the specific fevers have pre- 
ceded the development of the disease, but probably have no special connec- 
tion with it. In this country many cases have now been reported. 

Symptoms. — In a well-marked case the disease presents most char- 
acteristic features. The hands and feet are greatly enlarged, but are not 
deformed, and can be used freely. The hypertrophy is general, involving 
all the tissues, and gives a curious spade-like character to the hands. The 
lines on the palms are much deepened. The wrists may be enlarged, but 
the arms are rarely affected. The feet are involved like the hands and are 
uniformly enlarged. The big toe, however, may be much larger in propor- 
tion. The nails are usually broad and large, but there is no curving, and the 
terminal phalanges are not bulbous. The head increases in volume, but not 
as much in proportion as the face, which becomes much elongated and en- 
larged in consequence of the increase in the size of the superior and inferior 
maxillary bones. The latter in particular increases greatly in size, and often 
projects below the upper jaw. The alveolar processes are widened and the 
teeth separated. The soft parts also increase in size, and the nostrils are 
large and broad. The eyelids are sometimes greatly thickened, and the 
ears enormously hypertrophied. The tongue in some instances becomes 
greatly enlarged. Late in the disease the spine may be affected and the 
back bowed — kyphosis. The bones of the thorax may slowly and pro- 
gressively enlarge. With this gradual increase in size the skin of the hands 
and face may appear normal. Sometimes it is slightly altered in color, 
coarse, or flabby, but it has not the dry, harsh appearance of the skin in 
myxcedema. The muscles are sometimes wasted. Changes in the thyroid 



ACROMEGALY. 



1143 



have been found, but are not constant. The gland lias been normal in 
some, atrophied in others, and in a third group of cases enlarged. Erb, who 
has made an elaborate study of the disease, has noticed an area of dulness 
over the manubrium sterni, which he thought possibly due to the persist- 
ence or enlargement of the thymus. Headache is not uncommon. Somno- 
lence has been noted in many cases. Menstrual disturbance may occur 
early, and there may be suppression. Ocular symptoms are common. Hertel 
has analyzed 175 recorded cases, 92 of which presented eye complications. 
In three fourths of these the optic nerves were affected — usually atrophy, 
rarely neuritis. Bitemporal hemianopia is often an early sign. The disease 
may persist for fifteen, twenty, or more years. 

Pathological Anatomy. — Furnival has recently analyzed the recorded au- 
topsies, 34 in number. Changes in the pituitary gland were found in all, 
and in the majority there was hypertrophy or tumor. In 24 cases in which 
it was examined the thyroid was normal in 5, hypertrophied in one half; the 
thymus in 17 examined was absent in 7, hypertrophied in 3, and persistent 
in 7. In Osborne's case the heart was enormous, weighing 2 pounds 9 
ounces. 

Owing to the remarkable changes in the pituitary gland in acromegaly, 
it has been suggested that the disease is a nutritional disturbance analogous 
to myxoedema, and caused directly by disturbance in the function of this 
organ. The evidence from comparative anatomy and embryology shows 
that the pituitary body is a very " complex organ, consisting of an anterior 
secreting glandular organ; a water-vascular duct; a posterior, sensitive, 
nervous lobe, of which the last two — namely, the duct and the nervous lobe 
— were morphologically well developed and functioned in ancestral verte- 
brates, but have become obliterated and atrophied in structure and func- 
tion forever above larval acraniates " (Andriezen, British Medical Journal, 
1894, i). The pituitary body continues active, but the duct is obliterated 
" and the gland changed into a ductless gland; the secretion becomes an 
'internal secretion/" which is absorbed by the lymphatics. The extraor- 
dinary frequency with which the pituitary is involved in this disease lends 
weight' to the view that it is, in the words of Woods Hutchinson, 
the growth centre, or at any rate the proportion regulator of the skeleton. 

It has been suggested by Massalongo and others that gigantism and 
acromegaly are one and the same disease, both due to the superfunction 
of the pituitary gland. Certain persons exhibited as giants, or who have 
been " strong men " and wrestlers, have become acromegalic, and the skulls 
of some notable giants show enormous enlargement of the sella turcica. 

There is a congenital progressive hypertrophy of one extremity or of a 
part of it or of one side of the body — the so-called giant growth, which does 
not appear to have any connection with acromegaly. 

The treatment does not appear to have any influence upon the progress 
of the disease. The thyroid extract has been tried in many cases, without, 
so far as my personal experience goes, any benefit. Extract of the pituitary 
gland has also been used. The lung extract has been employed in some 
cases of pulmonary osteo-arthropathy. In a case of Caton's, of Liverpool, 
an unsuccessful attempt was made to extirpate the pituitary body. 



1144 



DISEASES OF THE NERVOUS SYSTEM. 



Osteitis Deformans (Pagefs Disease). 

In this remarkable affection the shafts of the long hones are chiefly 
involved, and in the head the bones of the cranium, bnt not those of the 
face. It :s a rare disease. The bones enlarge and soften, and those bear- 
ing weight become unnaturally curved and misshapen. At its commence- 
ment, and sometimes through all its course, it is attended with pains in the 
affected bones. 

The bone structure shows a mixture of rarefying osteitis, with the 
Haversian canals large and irregular, and of formative osteitis, with cer- 
tain Haversian canals narrowed and lamellae of recent formation. 

There is an intimate relation between osteitis deformans and the forma- 
tion of malignant tumors. Of 8 cases traced to the end, 5 died with cancer 
or sarcoma. 

About 60 cases have now been recorded, most of them in England. 
Seven have been reported in America. A most typical case is one re- 
ported by Watson in the Johns Hopkins Hospital Bulletin for June, 1898. 
I saw the man first in July, 1897. At the age of forty-two he was strong 
and healthy, measuring 5 feet llf inches in height. His tibiae began to 
enlarge and bow forward and outward, the thoracic spine to curve, and the 
cranial bones to enlarge. These changes have progressed. At the age 
of sixty-two, when first seen, owing to the bowing of the spine and lower 
extremities, his height was about 5 feet 2^ inches, or 9^ inches less than 
formerly. The circumference of his head had increased 3 T ig- inches. His 
thorax was almost perfectly quadrilateral. His intellect was unimpaired, 
and his general health was fairly good (Watson). 

As Marie states, in Paget's disease the face is triangular with the base 
upward; in acromegaly it is ovoid or egg-shaped with the large end down- 
ward; while in myxcedema it is round and full-moon-shaped. 

Concerning the etiology of the disease, absolutely nothing is known. 
No method of treatment has had the slightest influence upon its progress. 

Hypertrophic Pulmonary Arthropathy. 

Marie has given the name hypertrophic pulmonary osteo-arthropathy to 
a remarkable disorder, first recognized by Bamberger, characterized by en- 
largement of the hands and feet, and of the ends of the long bones, chiefly 
of the lower three fourths of the forearm and legs. Unlike acromegaly, 
the bones of the skull and of the face are not involved. The terminal 
phalanges are much spread with both transverse and longitudinal curves; 
the nails, too, are large and much curved over the ends of the phalanges. 
Scoliosis and kyphosis are rarely seen. The disease is very chronic, and in 
nearly all cases has been associated with some long-standing affection of 
the bronchi, lungs, or pleura (hence the name pulmonary 'osteo-arthropathy), 
of which sarcoma, chronic bronchitis, chronic tuberculosis, and empyema 
have been the most frequent. There are several instances in which the 
affection has developed in the subjects of syphilis. It occurs usually in 
adults and in the male sex. Thayer has reported 4 cases from my clinic 



SCLERODERMA. 



1145 



and lias collected 55 typical cases from the literature. Forty-three showed 
preceding pulmonary affection; of the remaining, 3 followed syphilis, 3 
heart-disease, 2 chronic diarrhoea, 1 spinal caries, and 3 unknown causes. 

The essential pathology of the disease is very obscure. Marie suggests 
that the toxines of the pulmonary disease are absorbed into the circulation 
and exercise an irritant action on the bony and articular structures, caus- 
ing an ossifying periostitis. Thorburn thinks that it is a chronic tubercu- 
lous affection of a large number of bones and joints of a benign type. 

Leontiasis Ossea. 

Finally, in a remarkable condition known as leontiasis ossea, there is 
hyperostosis of the bones of the cranium, and sometimes those of the face. 
The description is largely based upon the skulls in museums, but Allen 
Starr has recently reported an instance in a woman, who presented a slowly 
progressing increase in the size of the head, face, and neck, the hard and 
soft tissues both being affected. He has applied to the condition the term 
megalo-cephaly. Putnam states that the disease begins in early life, often 
as a result of injury. There may be osteophytic growths from the outer or 
inner tables, which in the latter situation may give the symptoms of tumor. 

MlCROMEGALY. 

A remarkable condition, the antithesis of acromegaly, has been de- 
scribed by Jonathan Hutchinson and Hastings Gilford (Lancet, 1896, ii, p. 
1227) as " mixed premature and immature development." The name micro- 
megaly is suggested by Gilford, who describes it as a disease of that part of 
the nervous system presiding over nutrition, which manifests itself in a 
smallness and immaturity of some parts 'or functions and a relative or 
actual largeness or prematurity of others. 



VI. SCLERODERMA. 

Definition. — A condition of localized or diffuse induration of the 
skin. 

Lewin and Heller (Die Sclerodermic, Berlin, 1895) have recently col- 
lected from the literature 508 cases. 

Two forms are recognized: the circumscribed, which corresponds to 
the keloid of Addison, and to morphcea; and the diffuse, in which large 
areas are involved. 

The disease affects females more frequently than males. The cases 
occur most commonly at the middle period of life. The sclerema neona- 
torum is a different affection, not to be confounded with it. The disease is 
more common in this country than statistics indicate. I have reported 8 
cases (Jour, of Genito-Urinary and Cutaneous Diseases, January, 1898), 
since which date I have seen 3 additional cases. 

In the circumscribed form there are patches, ranging from a few centi- 



1146 



DISEASES OF THE NERVOUS SYSTEM. 



metres in diameter to the size of the hand or larger, in which the skin has 
a waxy or dead-white appearance, and to the touch is brawny, hard, and 
inelastic. Sometimes there is a preliminary hyperemia of the skin, and 
subsequently there are changes in color, either areas of pigmentation or of 
complete atrophy of the pigment — leucoderma. The sensory changes are 
rarely marked. The secretion of sweat is diminished or entirely abolished. 
The disease is more common in women than in men, and is situated most 
frequently about the breasts and neck, sometimes in the course of the 
nerves. The patches may develop with great rapidity, and may persist for 
months or years; sometimes they disappear in a few weeks. 

The diffuse form, though less common, is more serious. It develops 
first in the extremities or in the face, and the patient notices that the skin 
is unusually hard and firm, or that there is a sense of stiffness or tension 
in making accustomed movements. Gradually a diffuse, brawny indura- 
tion develops and the skin becomes firm and hard, and so united to the 
subcutaneous tissues that it cannot be picked up or pinched. The skin 
may look natural, but more commonly is glossy, drier than normal, and 
unusually smooth. With reference to the localization, in 66 observations 
the disease was universal; in 203, regions of the trunk were affected; in 
193, parts of the head or face; in 287, portions of one or other of the upper 
extremities; and in 122, portions of the lower extremities. In 80 cases 
there were disturbances of sensation. The disease may gradually extend 
and involve the skin of an entire limb. When universal, the face is ex- 
pressionless, the lips cannot be moved, mastication is hindered, and it may 
become extremely difficult to feed the patient. The hands become fixed and 
the fingers immobile, on account of the extreme induration of the skin 
over the joints. Eemarkable vaso-motor disturbances are common, as ex- 
treme cyanosis of the hands and legs. In one of my cases tachycardia was 
present. The disease is chronic, lasting for months or years. There are 
instances on record of its persistence for more than twenty years. Eecovery 
may occur, or the disease may be arrested. The patients are apt to suc- 
cumb to pulmonary complaints or to nephritis. Eheumatic troubles have 
been noticed in some instances; in others, endocarditis. Eaynaud's disease 
may be associated with it, as in 2 eases described by Stephen Mackenzie. I 
have seen an instance of the diffuse form in which the primary symptoms 
were those of local asphyxia of the fingers, and in which, with extensive 
scleroderma of the arms and hands and face, there were cyanosis and swell- 
ing of the skin of the feet without any brawny induration. The pigmenta- 
tion of the skin may be as deep as in Addison^s disease, for which cases have 
been mistaken; scleroderma may occur as a complication of exophthalmic 
goitre. 

The remarkable dystrophy known as sclerodactylie belongs to this dis- 
order. There are symmetrical involvements of the fingers, which become 
deformed, shortened, and atrophied; the skin becomes thickened, of a 
waxy color, and is sometimes pigmented. Bullae and ulcerations have 
been met with in some instances, and a great deformity of the nails. The 
disease has usually followed exposure, and the patients are much worse 
during the winter, and are curiously sensitive to cold. There may be 



SCLERODERMA. 



1147 



changes in the skin of the feet, but the deformity similar to that which 
occurs in the hand has not been noted. Some of the cases present in addi- 
tion diffuse sclerodermatous changes of the skin of other parts. In Lewin 
and Heller's monograph there are 35 cases of isolated sclerodactylism, and 
106 cases in which it was combined with scleroderma. 

The pathology of the disease is unknown. It is usually regarded as a 
tropho-neurosis, probably dependent upon changes in the arteries of the 
skin leading to connective-tissue overgrowth. The thyroid has been found 
atrophied. 

Treatment. — The patients require to be warmly clad and to be 
guarded against exposure, as they are particularly sensitive to changes in 
the weather. Warm baths followed by frictions with oil should be sys- 
tematically used. I have tried the thyroid feeding thoroughly in the dif- 
fuse form without success. In a recent case of quite extensive localized 
scleroderma, after ten weeks' treatment, the patches are softer and the pig- 
mentation much less intense. Salol in 15-grain doses three times a day is 
stated to have been successful in several cases. 

AlNHUM. 

Here a brief reference may be made to the remarkable trophic lesion 
described by Da Silva Lima, which is met with in negroes in Brazil, Africa, 
India, and occasionally in the Southern States. It is confined to the toes, 
usually the little toe, and begins as a furrow on the line of the digito- 
plantar fold. This gradually deepens, the end of the toe enlarges, and, 
usually without inflammation or pain, the toe falls off. The process may 
last some years. Cases have been reported in this country by Hornaday, 
Pittman, F. J. Shepherd, and Morrison. 



SECTION XL 



DISEASES OF THE MUSCLES. 



I. MYOSITIS. 

Definition. 1 — Inflammation of the voluntary muscles. 

A primary myositis occurs as an acute or subacute affection, and is 
probably dependent on some unknown infectious agent. Several charac- 
teristic cases have been described of late years. That of E. AVagner may 
be taken as a typical example. A tuberculous but well-built woman entered 
the hospital, complaining of stiffness in the shoulders and a slight oedema 
of the back of the hands and forearms. There was paresthesia, the arms 
became swollen, the skin tense, and the muscles felt doughy. Gradually 
the thighs became affected. The disease lasted about three months. The 
post mortem showed slight pulmonary tuberculosis; all the muscles except 
the glutei, the calf, and abdominal muscles were stiff and firm, but fragile, 
and there were serous infiltration, great proliferation of the interstitial 
tissue, and fatty degeneration. Similar cases have been reported by Un- 
verricht, Hepp, and Jacoby, of New York. In the case reported by Jacoby 
the muscles were firm, hard, and tender, and there was slight oedema of the 
skin — dermato-myositis. The cases usually last from one to three months, 
though there are instances in which it has been longer. The swelling and 
tenderness of the muscles, the oedema, and the pain naturally suggest trichi- 
nosis, and indeed Hepp speaks of it as a pseudo-trichinosis. The nature of 
the disease is unknown. Senators case presented marked disorders of 
sensation, and there is a question whether the peripheral nerves are not 
involved with the muscles. Wagner suggests that some of these eases were 
examples of acute progressive muscular atrophy. The separation from 
trichinosis can be made only by removing a portion of the muscle. It has 
not yet been determined whether the eosinophilia described by Brown is 
peculiar to the trichinous myositis. There are septic cases in which a dif- 
fuse, purulent infiltration of the muscles of different regions occurs. In- 
stances have been reported in which this has been described as the primary 
affection, the condition of the muscles even passing on to gangrene. 
1148 



MYOTONIA. 



1149 



Myositis Ossificans Pkogressiva. 

Of this rare and remarkable affection 42 cases have been recorded (Mat- 
thes). The process begins within the neck or back, usually with swelling 
of the affected muscles, redness of the skin, and slight fever. After 
subsiding an induration remains, which becomes progressively harder as 
the transformation into bone takes place. The disease is very chronic, and 
ultimately may involve a majority of the skeletal muscles. Nothing is 
known of the etiology; the condition has often been associated with mal- 
formations. 

II. MYOTONIA (Thomsen's Disease). 

Definition.— An infection characterized by tonic cramp of the mus- 
cles on attempting voluntary movements. The disease received its name 
from the physician who first described it, in whose family it has existed 
for five generations. 

While the disease is in a majority of cases hereditary, hence the name 
myotonia congenita, there are other forms of spasm very similar which may 
be acquired, and others still which are quite transitory. 

Etiology. — All the typical cases have occurred in family groups; a 
few isolated instances have been described in which similar symptoms have 
been present. The disease is rare in this country and in England; it seems 
more common in Germany and in Scandinavia. 

Symptoms. — The disease comes on in childhood. It is noticed that 
on account of the stiffness the children are not able to take part in ordi- 
nary games. The peculiarity is noticed only during voluntary movements. 
The contraction which the patient wills is slowly accomplished; the relaxa- 
tion which the patient wills is also slow. The contraction often persists for 
a little time after he has dropped an object which he has picked up. In 
walking, the start is difficult; one leg is put forward slowly, it halts from 
stiffness for a second or two, and then after a few steps the legs become 
limber and he walks without any difficulty. The muscles of the arms and 
legs are those usually implicated; rarely the facial, ocular, or laryngeal mus- 
cles. Emotion and cold aggravate the condition. In some instances there 
is mental weakness. The sensation and the reflexes are normal. G. M. 
Hammond has reported three remarkable cases in one family, in which the 
disease began at the eighth year and was confined entirely to the arms. It 
was accompanied with some slight mental feebleness. The condition of the 
muscles is interesting. The patients appear and are muscular, and there 
is sometimes a definite hypertrophy of the muscles. The force is scarcely 
proportionate to the size. Erb has described a characteristic reaction of 
the nerve and muscle to the electrical currents — the so-called myotonic 
reaction, the chief feature of which is that normally the contractions caused 
by either current attain their maximum slowly and relax slowly, and ver- 
micular, wave-like contractions pass from the cathode to the anode. 

The disease is incurable, but it may be arrested temporarily. The na- 
ture of the affection is unknown. In the only autopsy made Dejerine and 



1150 



DISEASES OF THE MUSCLES. 



Sottas have found hypertrophy of the primitive fibres with multiplication 
of the nuclei of all the muscles, including the diaphragm, but not the 
heart. The spinal cord and the nerves were intact. From Jacoby's recent 
studies it is doubtful whether these changes in the muscles are in any way 
characteristic or peculiar to the disease. JSTo treatment for the condition is 
known. 

III. PARAMYOCLONUS MULTIPLEX 

(Myoclonia). 

An affection, described by Friedreich, characterized by clonic contrac- 
tions, chiefly of the muscles of the extremities, occurring either constantly 
or in paroxysms. 

The cases have been chiefly in males, and the disease has followed emo- 
tional disturbance, fright, or straining. The contractions are usually bilat- 
eral and may vary from fifty to one hundred and fifty in the minute. Occa- 
sionally tonic spasms occur. They are not accompanied by any sensory 
disturbances. In the intervals between the attacks there may be tremors of 
the muscles. In the severe spasms the movements may be very violent; the 
body is tossed about, and it is sometimes difficult to keep the patient in bed. 
Gucci has described a family in which the affection has occurred in three 
generations. 

Weiss has also noted heredity in four generations. According to this 
author the essential symptoms are continuous or paroxysmal muscular con- 
tractions, usually symmetrical and rhythmical, of muscles otherwise normal, 
which cease during sleep. There are neither psychical nor sensory disturb- 
ances. The condition is most common in young males, and is unaffected 
by treatment. Eaymond groups this disease with fibrillary tremors, electric 
chorea (Henoch), tic non douloureux of the face, and the convulsive tic, 
under the name of myoclonies, believing that it is only one link in a chain 
of pathological manifestations in the degenerate. 



INDEX. 



Abasia, 1126, 1136. 
Abdominal typhus, 1. 

Abducens nerve (see Sixth Nerve), 1048. 

Aberrant, thyroid glands, 836; adrenals, 896. 

Abortion, in relapsing fever, 55; in small- 
pox, 65; in syphilis, 251. 

Abscess, atheromatous, 771; of brain, 1025; 
in appendicitis, 522, 526; in glanders, 235; 
of kidney (pyonephrosis), 886; of liver, 
577; of lung, 662; of mediastinum, 686; of 
parotid gland, 447; of tonsils, 452; peri- 
nephric, 900; cerebral, 1025; pysemic, 163; 
retro-pharyngeal, 450, 971. 

Acanthocephala, 365. 

Acardia, 765. 

Acarus scabiei, A. folliculorum, 376. 
Accentuated aortic second sound, in chronic 

Bright's disease, 881; in arterio-sclerosis, 

774. 

Accessory spasm, 1064. 
Acephalocysts (see Hydatid Cysts). 
Acetonemia, 426. 
Acetone, 424; tests for, 424. 
Acetonuria, 864. 
Achondroplasia, 841. 
Achromatopsia in hysteria, 1116. 
Achylia gastrica, 501. 

Acne, from bromide of potassium, 1101; 
rosacea, 382. 

Acromegaly, 1142; and gigantism, 1143. 

Actinomycosis, 235; pulmonary, 236; cutane- 
ous, 237; cerebral, 237. 

Acute bulbar paralysis, 933. 

Acute yellow atrophy, 551. 

Addison's disease, 828; pill, 254; keloid, 
1145. 

AfJenie, 809. 

Adenitis in scarlet fever, 81. 
Adenitis, tuberculous, 282, 812; malignant, 
191. 

Adenoid growths in pharynx, 454. 
Adherent pericardium, 090. 
Adhesive pylephlebitis, 554. 
Adiposis dolorosa, 440. 
Adrenals in Addison's disease, 829. 
jEgophony, 120, 670. 
Afferent system, diseases of, 920. 
Ageusia, 1060. 



Agoraphobia, 1124. 
Agraphia, 992. 
Ague, 203. 

Ague cake (see Enlarged Spleen), 216. 
Ainhum, 1147. 

" Air-hunger " in diabetes, 426. 
Akinesia algera, 1126. 
Akoria, 503. 
Albini, nodules of, 767. 

Albinism, in leprosy (lepra alba), 341; of the 
lung, 656. 

Albumin, tests for, 856. 

Albuminous expectoration in pleurisy, 678. 

Albuminuria, 854, and life assurance, 858; 
cyclic, 855; febrile, 855; functional 855; in 
acute Bright's disease, 870; in chronic 
Bright's disease, 880: in diabetes, 424; in 
diphtheria, 150; in epilepsy, 1097; in ery- 
sipelas, 159; in gout, 415; in pneumonia, 
122; in scarlet fever, 79, 80; in typhoid 
fever, 31; in .variola, 64; neurotic, 855; 
physiological, 855; prognosis in, 858. 

Albuminuric retinitis, 1039. 

Albuminuric ulceration of the bowels, 513. 

Albumosuria, 857. 

Alcaptonuria, 865. 

Alcohol, effects of, on the digestive system, 
381; on the kidneys, 382; on the nervous 
system, 381; poisonous effects of, 381. 

Alcoholic neuritis, 1034. 

Alcoholism, 380; acute, 380; and tuberculo- 
sis, 382; chronic, 380. 
Alexia, 992. 

Algid form of malaria, 215. 
Allantiasis, 391. 
Alloeheiria. 924. 
Allbrrhythmia, 756. 
Alopecia, in syphilis, 241. 
Alternating paralysis (see Crossed Paraly- 
sis). 

Altitude, effects of high. 346. 
Altitude in tuberculosis. 2.~9. 334. 
Amaurosis, hysterical. 1040. 1110; toxic. 

1040; uremic, 867, 881; in hsematemesis, 

496. 

Amblyopia, 1040; tobacco, 1040; crossed, 
1044. 

Ambulatory typhoid fever. 14. 34. 

1151 



1152 



INDEX. 



Amoeba coli (amoeba dysenteriae), 195; in 

liver abscess, 195, 577; in sputa, 201. 
Amcebic dysentery, 195. 
Ammonia? rnia, 888. 
Amnesia verbalis, 991. 
Amphoric breathing, 309, 683. 
Amphoric echo, 309. 
Amusia, 991. 

Amyloid disease, in phthisis, 298; in syphilis, 
242; of kidney, 884; of liver, 586. 

Amyosthenia, 1125. 

Amyotrophic lateral sclerosis, 928. 

Anaemia, 789; bothriocephalus, 367; in anchy- 
lostomiasis, 360; from Bilharzia, 352; in 
chlorosis, 792; from gastric atrophy, 469; 
from haemorrhage, 789; miner's, 360; brick- 
maker's 360; tunnel, 360; from inanition, 
791; from lead, 387; idiopathic, 795; in gas- 
tric cancer, 489; in gastric ulcer, 482; 
mountain, 346. 360: in malarial fever, 216; 
in rheumatism, 170; in syphilis, 240; in 
typhoid fever, 19; primary or essential, 
792; progressive pernicious. 795; secondary 
or symptomatic, 789: of spinal cord, 966; 
splenic, 834; toxic, 791. 

Anaemic murmurs (see Hjemic Murmurs). 

Anaesthesia, dolorosa, 970; in hemiplegia, 
1005; in hysteria, 1115; in leprosy, 342; in 
locomotor ataxia, 924; in Morvan's dis- 
ease, 975; paralysis, 1035; pneumonia, 129; 
in railway spine, 1134; in unilateral lesions 
of the cord, 965. 

Analgesia in hysteria, 1115: in Morvan's dis- 
ease, 975; in syringo-myelia, 975. 

Anarthria, 989. 

Anasarca (see Dropsy). 

Ankylostomiasis, 359. 

Anchylostomum duodenale, 359. 

Aneurism, 776; arterio-venous, 776, 788; cir- 
soid, 776; congenital, 788; cylindrical, 776; 
dissecting, 776; embolic, 776; false, 776; 
fusiform, 776; mycotic, 776; of the ab- 
dominal aorta, 786; of the branches of the 
abdominal aorta, 787; of the cerebral ar- 
teries, 1013; of the coeliac axis, 787; of 
heart, 753; of the hepatic artery, 787; of 
the renal artery, 787; of the splenic artery, 
787; of the superior mesenteric artery, 787; 
true, 776. 

Aneurism, of thoracic aorta, 777: haemor- 
rhage in, 781; pain in. 781; Tufnell's treat- 
ment of, 784; unilateral sweating in. 782. 

Aneurism, verminous, in the horse, 359, 777. 

Angina, Ludovici. 450; simplex, 448; suffo- 
cativa, 138. 

Angina pectoris. 761; pseudo- or hysterical, 
763: toxic. 764: vaso-motoria, 764. 

Angiocholitis, chronic catarrhal, 557; suppu- 
rative and ulcerative, 557. 

Angio-neurotic oedema, 1140. 



Angio-sclerosis, 773. 

Anguillula stercoralis, A. intestinalis, 364. 
Animal lymph, 72. 
Anisocoria, 1047. 

Ankle clonus, in hysterical paraplegia, 941. 
1114; in spastic paraplegia, 937; spurious, 
1114. 

Anorexia nervosa, 503, 1117. 
Anosmia, 1038. 

Anterior cerebral artery, embolism of, 1011. 

Anterior crural nerve, paralysis of, 1072. 

Anthomyia canicularis, 378. 

Anthracosis, of lungs, 652; of liver, 570. 

Anthrax, 224; bacillus, 224; in animals, 224; 
external, 225; internal, 226. 

Anthropophobia, 1124. 

Antipneumococcic serum, 112. 

Antitoxine of diphtheria, 141, 155; of pneu- 
monia, 112: of tetanus, 233. 

Antityphoid serum, 46. 

Anuria, 850; complete, from stone, 850; hys- 
terical, 851. 
Anus, imperforate, 533. 

Aorta, aneurism of, 777 ; dynamic pulsation 
of, 782; throbbing, 786, 1126; tuberculosis 
of, 327. 

Aortic incompetency, 709: sudden death in, 
712. 

Aortic orifice, congenital lesions of, 767. 
Aortic stenosis, 715. 

Aortic valves, bicuspid condition of, 766; in- 
sufficiency of, 709. 
Apex pneumonia, 126. 

Aphasia, 988; auditory, 991; in infantile 
hemiplegia, 1018; medico-legal aspects of, 
993; motor, 992; in phthisis, 312; prognosis 
of, 993; sensory, 991; subcortical-motor, 
993; in typhoid fever, 30; tests for, 993; 
transient, in migraine, 1103; visual, 992. 

Aphemia, 989. 

Aphonia, hysterical, 1116; in acute laryn- 
gitis, 615; in adductor paralysis, 1061; in 
pericardial effusion. 692. 

Aphthae (see Stomatitis, Aphthous), 441. 

Aphthous fever, 347. 

Apoplectic habitus, 998; stroke, 1001. 

Apoplexy, cerebral, 997; ingravescent, 1001; 
pulmonary. 638. 

Appendicitis. 519: obliterans, 520: infective, 
521; perforative, 520; relapsing, 527; ul- 
cerative, 521. 

Appendicular colic, 520, 524. 

Appendix vermiformis, situation of. 519: per- 
foration of, in typhoid fever, 10: faecal 
concretions in, 519: foreign bodies in, 520; 
necrosis and sloughing of, 521. 

Apraxia, 992. 

Aprosexia, 454, 456. 

Arachnida. parasitic, 375. 

Arachnitis (see Meningitis), 954. 



INDEX. 



1153 



Aran-DucJienne type of muscular atrophy, 

929, 941; in lead-poisoning, 388. 
Arch of aorta, aneurism of, 778. 
Arcus senilis, 750. 

Argyll Robertson pupil, 1047; in ataxia, 922. 
Arithmomania, 1089. 

Arm, peripheral paralysis of (see Paralysis 

of Brachial Plexus). 
Arrhythmia, 756. 
Arsenical neuritis, 1035. 

Arsenical pigmentation, 390; in chorea, 1085. 
Arsenical poisoning, 390; paralysis in, 391. 
Arteries, diseases of, 770; calcification of, 

770; degeneration of, 770; tuberculosis of, 

327. 

Arterio-capillary fibrosis, 770. 

Arterio-sclerosis, 770; diffuse, 772; in lead- 
poisoning, 389; in migraine, 1103; nodular 
form, 771; in phthisis, 316; senile form, 
772. 

Arteritis in typhoid fever, 12, 21; syphilitic, 
250. 

Arthralgia from lead, 389. 

Arthritides, post-febrile, 165; in gout, 414. 

Arthritis, 173; acute, in infants, 173; gonor- 
rhoeal, 256; in acute myelitis, 977; in 
cerebro-spinal meningitis, 106; in chorea, 
1080; in dengue, 100; in dysentery, 200; in 
haemophilia, 820; in Malta fever, 220; in 
small-pox, 65; in tabes dorsalis, 925; mul- 
tiple secondary, 173; in purpura, 815; 
rheumatoid, 399; in scarlet fever, 80; sep- 
tic, 173; in typhoid fever, 32. 

Arthritis deformans, 399; as a chronic infec- 
tion, 400; in children, 403; general progres- 
sive form, 402; Heberdcn's nodes in, 401; 
partial or mono-articular form, 403; verte- 
bral form, 403. 

Arthropathies in tabes, 925. 

Arthropathy, hypertrophic pulmonary, 1144. 

Ascariasis, 352. 

Ascaris lumbricoides, 352. 

Ascites, 605, 609; from cancerous peritonitis, 
605; from cirrhosis of the liver, 572; from 
syphilis of the liver, 249; in cancer of the 
liver, 584; in tuberculous peritonitis, 287; 
physical signs of, 606; treatment of, 607. 

Ascitic fluid, chylous, 607; serous, 607; ha?m- 
orrhagic, 607. 

Aspergillus in lung, 302. 

Asphyxia, local, 1137; death by, in phthisis, 
317. 

Aspiration, Bowditch's conclusions on, 677; 

in empyema, 678; in pericardial effusion, 

695; in pleuritic effusion, 677. 
Aspiration pneumonia, 642. 
Astasia-abasia, 1126, 1136. 
Asthenic bulbar paralysis, 947. 
Asthenopia, nervous, 1124. 
Asthma, bronchial, 628; nasal affections in, 
72 



629; sputum in, 630; cardiac, 628; hay, 612; 
Leyden's crystals in, 631; renal, 628, 867; 
thymic, 618, 844. 
Astrophobia, 1124. 

Atavism, in haemophilia, 819; in gout, 408. 

Ataxia, cerebellar, 987; cerebellar-heredo, 
950; hereditary, 949; in progressive pare- 
sis, 962; locomotor, 920; after small-pox, 
64. 

Ataxic gait, 923. 

Ataxic paraplegia, 948. 

Atelectasis, pulmonary, 642. 

Atheroma (see Arterio-sclerosis and 

Phlebo-sclerosis). 
Athetosis, 1019; bilateral or double, 939. 
Athlete's heart, 710. 
Athyrea, 837, 840. 

Atmospheric pressure, effects of, 969. 
Atremia, 1126. 

Atrophy, acute yellow, of liver, 551; of brain, 
diffuse, in general paresis, 961; of brain, 
unilateral, 1017; of muscles, various forms 
of, 935; progressive muscular, of central 
origin, 928; unilateral, of face, 1141. 

Attitude, in pseudo-hypertrophic muscular 
paralysis, 934; in paralysis agitans, 1077.. 

Auditory centre, affections of, 1056; nerve, 
diseases of, 1056; vertigo, 1058. 

Aura, forms of, in epilepsy, 1095. 

Auto-infection in tuberculosis, 273. 

Automatism, in petit mat, 1097; in cerebral 
syphilis, 246. 

Autumnal fever, 3. 

Avian tuberculosis, 258. 

BaccellVs sign, 670, 672. 

Bacilluria in typhoid fever, 31. 

Bacillus, anthracis, 224; of cholera, 175. 

Bacillus coli communis— distinction from ty- 
phoid bacillus, 4; in bile-passages, 558; in 
faeces of sucklings, 50S; in fat necrosis 
with colitis, 591; in peritonitis, 597. 

Bacillus diphtheria?, 140, 451; value of, in 
diagnosis, 151. 

Bacillus gas (B. aerogenes capsulatus), in 
peritonitis, 597: in pneumaturia, 864: in 
pneumopericardium, 60S. 

Bacillus icteroides, 184. 

Bacillus, Klebs-Loeffler. 140; toxine of, HI. 

Bacillus, of glanders, 233; of influenza, 96; 
of smegma, 238; in whooping-cough, 92; of 
leprosy, 340; of plague, 1!*): of syphilis, 
238; of tetanus, 231; pyocyaneus, 163; 
StreptO-, in typhus fever, 50. 

Bacillus mallei. 233. 

Bacillus pestis, 190. 

Bacillus pneumoniae, 111. 

Badlllia proteus fluorescens, 344. 

Bacillus smegma, 23S. 

Bacillus tuberculosis, 259, 066; diagnostic 



1154 



INDEX. 



value of, 318; distribution of, 261; in spu- 
tum, 300; methods of detection, 301; out- 
side the body, 261; products of growth of, 
260. 

Bacillus typhosus, 3. 
Bacillus xerosis, 141. 
Bactersemia, 161. 

Bacteria, proteus group in diarrhoea, 509; 

relation to diarrhoea, 508. 
Bacterium, coli commune (see Bacillus 

Coli Communis); lactis aerogenes, 508. 
Balanitis in diabetes, 425. 
Balantidium coli, 351. 
Ball-thrombus in left auricle, 723. 
Ball-valve stone in common duct, 566. 
Bo7iting's method in obesity, 440. 
" Barben cholera," 394. 
Barking cough of puberty, 1117. 
Barlow's disease, 825. 

Barrel-shaped chest in emphysema, 658; in 

enlarged tonsils, 455. 
Basilar artery, embolism and thrombosis of, 

1010. 

Baths, cold, in typhoid fever, 43; in hyperpy- 
rexia of rheumatism, 175; in scarlet fever, 
84. 

Batophobia, 1124. 
Beaded ribs in rickets, 436. 
Bed-bug, 377. 
Bednar's aphthae, 443. 

Bed-sores, acute, in myelitis. 977, 978; in ty- 
phoid fever, 18. 

Beer-drinkers, heart-disease in, 745. 

Bell's (Luther) mania, 1075. 

BelVs palsy, 1051. 

/}-oxy-butyric acid, 426, 865. 

Beri-beri, 220; forms of, 222. 

Besoin de respirer, 346. 

Biernacki's symptom, 963. 

"Big-jaw" in cattle, 235. 

Bile coloring matter, tests for, 549. 

Bile-ducts, acute catarrh of, 555: ascarides 
in, 560; cancer of, 559: congenital oblitera- 
tion of, 561; stenosis of, 560. 

Bile-passages, diseases of, 555. 

Bilharzia haeraatobia, 352. 

Biliary cirrhosis of liver, 570. 

Biliary colic, 563. 

Biliary fistulae, 567. 

Bilious remittent fever, 213. 

Birth palsies, 938. 

Black death, 190. 

Black spit of miners, 654. 

Black vomit, 186; in dengue. 100. 

Black-water fever, 216. 

Bladder, paralysis of, in locomotor ataxia, 
922; care of, in myelitis, 979; hypertrophy 
of, in diabetes insipidus, 432; tuberculosis 
of, 325. 

" Bleeders," 819. 



Blood-letting, in arterio-sclerosis, 775; in 
cerebral haemorrhage, 1012; in emphy- 
sema, 659; in heart-disease, 731; in pneu- 
monia, 135; in sun-stroke, 398; in yellow 
fever, 189. 

Blepharospasm, 1055. 

Blindness (see Amaurosis). 

Blood and ductless glands, diseases of, 789. 

Blood, characters of, in anaemia, 789; in can- 
cer of the stomach, 489; in chlorosis, 792; 
in cholera, 178; in diabetes, 421; in gout, 
410; in haemophilia, 819; in leukaemia, 808; 
in pernicious anaemia, 797; in pseudo- 
leukaemia, Hodgkin's disease, 812; in pur- 
pura, 814; in secondary anaemia, 790; in 
typhoid fever, 19. 

Blood serum therapy in diphtheria, 155; in 
pneumonia, 112; in tetanus, 233; in ty- 
phoid fever, 46. 

Blood-vessels of liver, affections of, 553. 

" Blue disease," 768. 

Blue line on gums in lead-poisoning, 387. 
Boils, in diabetes, 425; after typhoid fever, 

18; after small-pox, 65. 
Bones, lesions of, in acromegaly, 1142; in 

congenital syphilis, 244; in rickets, 434; in 

typhoid fever, 32. 
Borborygmi, 498, 507. 
Bothriocephalus latus, 366; anaemia, 367. 
Botulism, 391. 

Botyroid liver in syphilis, 249. 

Bovine tuberculosis, 258. 

Bowel, affections of (see Intestines); acute 
obstruction of, 534; infarction of, 546. 

Brachial plexus, affections of, 1069. 

Brachycardia (Bradycardia), 759; in ty- 
phoid fever, 20. 

Brain, diffuse and focal diseases of, 979; ab- 
scess of, 1025; abscess of, in congenital 
heart-disease, 768; affections of blood-ves- 
sels of, 994; anaemia of, 995; atrophy and 
sclerosis of, 1017; congestion of, 994; cysts 
in. 1021; eehinococcus of, 374; haemorrhage 
into, 997; syphilis of, 244, 1020; glioma of, 
1020: hyperaemia of, 994; inflammation of, 
1024; oedema of, 997; porencephalus of, 
1017. 

Brain-murmur in rickets. 437. 

Brain, sclerosis of, 957; diffuse, 958; insular, 

959; miliary. 958; tuberous. 959. 
Brain, softening of, red, yellow, and white, 

1009. 

Brain, tubercle of, 321. 1020. 

Brain, tumors of, 1020; medical treatment 
of. 1024; surgical treatment of, 1024; symp- 
toms, general and localizing, 1021. 

Brand's method in typhoid fever, 43. 

Breakbone fever (see Dengue), 99. 

Breast-pang. 761. 

Breath, odor of, in diabetic coma, 426: foul, 



INDEX. 



1155 



in scurvy, 823; foetid, in enlarged tonsils, 
456. 

Breathing (see Respiration); mouth, 454. 
Bremer's blood test in diabetes, 427. 
Brick-maker's anaemia, 360. 
Bright's disease, acute, 869; interstitial form 
of, 870. 

Bright's disease, chronic, 874; interstitial 
form of, 877; causes of, 877; cardio-vascular 
changes in, 880; hereditary influences in, 
877; parenchymatous form of, 875. 

Briquet, syndrome of, 1116. 

Broadbent's sign, 696. 

" Broken- winded," 742. 

Bromatotoxismus, 391. 

Bromism, 1100. 

Bronchi, casts of, 633; diseases of, 621. 

Bronchial asthma, 628. 

Bronchial catarrh (bronchitis), 621. 

Bronchial glands, tuberculosis of, 283; en- 
largement in whooping-cough, 94, 684; sup- 
puration in, 684. 

Bronchiectasis, 626; abscess of brain in, 627; 
congenital, 626; cylindrical, 626; rheuma- 
toid affections in, 627; saccular, 626; spu- 
tum in, 627; universalis, 626. 

Bronchiolitis exudativa, 628. 

Bronchitis, 621; acute, 621; capillary, 641. 

Bronchitis, chronic, 623. 

Bronchitis, fibrinous, 632. 

Bronchitis in measles, 87; in small-pox, 64; 
in typhoid fever, 27; putrid, 625. 

Bronchocele (see Goitre), 835. 

Bronchophony, in pneumonia, 120. 

Broncho-pneumonia, acute, 641; chronic, 649; 
acute tuberculous, 292. 

Bronchorrhagia, 637. 

Bronchorrhoea, 624; serous, 624. 

Bronze-skin in phthiriasis, 377; in Addison's 
disease, 830; in Basedow's disease, 839; in 
diabetes, 425; in Hodgkin's disease, 812. 

Brown atrophy of heart, 750. 

Brown induration of lung, 635. 

Broicn-Sequard's paralysis, 965. 

Bruit, d'airain, 683; de cuir neuf, 690; de 
diable, 794; de pot fele (see Cracked-pot 
Sound), 309; de souffle, 703; oesophageal, 
460. 

Bubo, parotid (see also Parotitis), 447. 
Bubonic plague, 189. 
Buccal psoriasis, 446. 
Buhl's disease, 818. 

Bulbar paralysis, 928, 932; acute, 933; as- 
thenic form, 947; of cerebral origin, 932; 
progressive, 928. 

Bulimia, 423, 502. 

Cachexia, in cancer of the stomach, 489; 
malarial, 208, 216; periosteal, 825; satur- 
nine, 387; strumipriva, 842; syphilitic, 240. 



Caisson disease, 969. 

Calcareous concretions, in phthisis, 295; in 
the tonsils, 456. 

Calcareous degeneration, of arteries, 770; of 
heart, 750. 

Calcification, annular, of arteries, 770. 

Calcification in tubercle, 271. 

Calculi, biliary, 561; " coral," 892; pan- 
creatic, 595; renal, 891; tonsillar, 456; uri- 
nary, 891. 

Calculous pyelitis, 886. 

Camp fever, 49. 

Cancer, of bile-passages, 559, 583; of bowel, 
533; of brain, 1020; of gall-bladder, 559; 
green, 809; of kidney, 896; of liver, 582; of 
lung, 663; of oesophagus, 461; of pancreas, 
594; of peritonaeum, miliary, 604; of 
stomach, 486; acute, 493. 

Cancrum oris, 444; in measles, 87. 

Canities, the result of neuralgia, 1104. 

Canned goods, poisoning by, 393. 

Capillary pulse, in aortic insufficiency, 714; 
in neurasthenia, 1126; in phthisis, 311. 

Capsule, internal, 982; lesions of, 983. 

Caput Medusae, 606. 

Caput quadratum, in rickets, 436. 

Carboluria, 865. 

Carbuncle in diabetes, 425. 

Cardia, spasm of, 499; insufficiency of, 500. 

Cardiac, compensation, rupture of, 741; dis- 
ease (see Disease of Heart). 

Cardiac murmurs, hcemic, in chlorosis, 794; 
in chorea, 1084; in idiopathic anaemia, 799. 

Cardiac murmurs, organic, in aortic insuffi- 
ciency, 713; in aortic stenosis, 716; in con- 
genital heart affections, 769; in mitral in- 
competency, 720; in mitral stenosis, 723; 
in tricuspid valve disease, 726. 

Cardiac nerves, neuralgia of, 761. 

Cardiac overstrain, 742. 

Cardiac septa, anomalies of, 766. 

Cardialgia (see Gastralgia). 

Cardiocentesis, 755. 

Cardio-respiratory murmur, 308. 

Cardio-sclerosis, 750. 

Cardio-vascular changes in renal disease, 
880. 

Caries, vertebral, 970. 
Carinated abdomen, 278. 

Carotid artery, ligature and compression of, 

in cerebral haemorrhage, 1012. 
Carphologia, 21). 
Carpo-pedal spasm, 1111. 
Carrcau, 288. 

Caseation in tubercle, 271. 
Caseous pneumonia, 272. 

Casts, blood, of bronchial tubes in hemopty- 
sis, 638; in fibrinous bronchitis. 633; of 
pelvis of kidney and ureter. 807. 

Casts of urinary tubules, 872; epithelial, 871, 



1156 



INDEX. 



872; fatty, 876; granular, 876, 880; hyaline, 
880. 

Casts, tube, in acute Bright's disease, 872; 

in chronic Bright's disease, 876, 880. 
Catalepsy in hysteria, 1119. 
Cataract, diabetic, 427; after typhoid fever, 

30. 

Catarrh, acute gastric, 463; autumnal, 612; 
bronchial, 621; chronic gastric, 466; dry, 
625; nasal, 611; simple chronic (nasal), 611; 
suffocative, 645. 

Catarrhal bronchitis, influence of, in tuber- 
culosis, 269. 

Catarrhe sec, 625. 

Catarrhus aestivus, 612. 

Cauda equina, lesions of, 972. 

Cavernous breathing, 309. 

Cavities, pulmonary, physical signs of, 309; 
quiescent, 297. 

Cayor fly, 379. 

Cellulitis of the neck, 450. 

Centrum semiovale, lesions of, 981. 

Cephalalgia (see Headache). 

Cephalic tetanus, 232. 

Cephalodynia, 407. 

Cercomonas intestinalis, 199, 351; C. homi- 
nis, 351. 

Cerebellar, ataxia, 950, 987; heredo-ataxia, 

950; vertigo, 9S6. 
Cerebellum, tumors of, 986; affections of, 

985. 

Cerebral arteries, aneurism of, 1013; arterio- 
sclerosis of, 1014; embolism of, 1008; en- 
darteritis of, 1014; syphilitic endarteritis 
of, 245, 1014; thrombosis of, 1008. 

Cerebral cortex, lesions of, 980. 

Cerebral haemorrhage, 997; aneurisms, mil- 
iary, in, 998; convulsions in, 1007; forms 
of, 999. 

Cerebral localization, 907. 

." Cerebral pneumonia," 122. 

" Cerebral rheumatism," 171. 

Cerebral sinuses, thrombosis of, 1015. 

Cerebral softening, 1008. 

Cerebritis (see Encephalitis), 1024. 

Cerebro-spinal fever, epidemic, 100; anom- 
alous forms of, 105; complications of. 105; 
malignant form, 103; ordinary form, 103. 

Cervical pachymeningitis, 953. 

Cervical plexus, lesions of, 1067. 

Cervico-brachial neuralgia, 1105. 

Cervico-occipital neuralgia, 1067, 1105. 

Cestodes, disease due to, 365; visceral, 368. 

Chalicosis, 652, 654. 

Chancre, 239. 

Charbon, 224. 

Charcot's joint, 925. 

Charcot-Lcyden crystals, 507, 631, 803. 

Chattering teeth, 1051. 

Cheek, gangrene of, 444. 



Cheese, poisoning by, 393. 

Chest expansion, diminution of, in Graves' 
disease, 839. 

Cheyne-Stokes breathing, Cheyne's original 
description of, 751; in apoplexy, 1001; in 
fatty heart, 751; in sun-stroke, 397; in 
acute tuberculosis, 275; in uraemia, 867. 

Chiasma and tract, affections of, 1041. 

Chicken-breast, 436, 455. 

Chicken-pox, 74. 

Child-growiug, 618. 

Children, constipation in, 540; diabetes in, 
425; tuberculous broncho-pneumonia in, 
292; pneumonia in, 126; tuberculosis of 
mesentric glands in, 283, 288; mortality 
from small-pox in, 65; rheumatism in, 167; 
typhoid fever in, 34. 

Chills (see Rigors), in typhoid fever, 17. 

Chloasma phthisicorum, 313. 

Chloro-anaeraia in phthisis, 311. 

Chloroma, 809. 

Chlorosis, 792; and anaemia, sinus thrombo- 
sis in, 1015; dilatation of stomach in, 794; 
Egyptian, 360; fever in, 794; heart symp- 
toms in, 794; menstrual disturbance in, 
795; thrombosis in, 794. 

Choked disk, 1040. 

Cholaemia, 550. 

Cholangitis, infective, 566; suppurative, 567, 

578; in typhoid fever, 26. 
Cholecystectomy, 569; indications for, 569. 
Cholecystitis acuta, 564. 
Cholecystitis, acute infective, 558. 
Cholecystotomy, 569. 

Cholelithiasis, 561; in typhoid fever, 27. 

Cholera, asiatica, 175; bacillus of, 175; epi- 
demics of, 175; infantum, 509; nostras, 180; 
sicca, 179; typhoid, 179. 

Cholera toxine, 176. 

Cholerine, 180. 

Cholestersemia, 550. 

Cholesterin in biliary calculi, 563. 

Choluria, 865. 

Chondrodystrophia foetalis, 841. 

Chorea, acute, 1079; etiology of, 1079; heart 
symptoms of, 1083; infectious origin of, 
1080; in pregnancy, 1080; paralysis in, 
1083; rheumatism and, 1079; school-made, 
1081. 

Chorea, canine, 1080; chronic, 1090. 

Chorea, habit or spasm, 1088. 

Chorea, Huntingdon's or hereditary, 1090. 

Chorea, insaniens, 1083, 1085; paralytic form 
of, 1083; major, 1088; pandemic, 1088; post- 
hemiplegic, 1019; prehemiplegic, 1001; 
rhythmic or hysterical, 1091; senile, 1090; 
spastica, 939, 1086; Sydenham's, 1079. 

Choroid plexuses, sclerosis of, 1029. 

Choroid, tubercles in, 279. 

Choroiditis in syphilis, 241. 



INDEX. 



1157 



ChovsteJc's symptom in tetany, 1110. 
Chylangiornata, 547. 
Chyle vessels, disorders of, 547. 
Chylo-pericardium, 698. 

Chyluria, non-parasitic, 859; parasitic, 361. 

Cicatricial stenosis of bowel, 533. 

Ciliary muscle, paralysis of, 1047. 

Ciliata, parasitic, 351.. 

Cimex lectularius, 377. 

Circulatory system, diseases of, 688. 

Circumcision, inoculation of tuberculosis by, 
264; in haemophilia, 820. 

Circumflex nerve, affections of, 1070. 

Cirrhosis, of kidney, 877; of liver, 569; of 
lung, 649; ventriculi, 467. 

Claudication, intermittent, 763. 

Claustrophobia, 1124. 

Claviceps purpurea, poisoning by, 394. 

Clavus hystericus, 1116. 

Claw-hand (main en griffe), 930, 953. 

Climate, influence of, in asthma, 632; in 
chronic Bright's disease, 882; in tubercu- 
losis, 333. 

Clonus (see Ankle Clonus); jaw, 931. 
Clownism in hysteria, 1113. 
Cnethocampa, 379. 

Cobalt miners, cancer of lung in, 664. 
Coccidium oviforme, 349. 
Coccydynia, 1106. 
Cochin-China diarrhoea, 365. 
Cceliac affection in children, 511. 
Cog-wheel respiration, 308. 
Coin-sound, 683. 

Cold pack, method of giving, 84. 

Colic, biliary, 563; in appendicitis, 520, 524; 
in angio-neurotic oedema, 1140; in purpura, 
816; lead, 388; mucous, 544; renal, 893. 

Colica Pictonum, 386. 

Colitis, diphtheritic, 512; mucous, 544; 

simple ulcerative, 513. 
Colles's law, 239. 

Colloid cancer, of lung, 663; of peritonaeum, 

604; of stomach, 487. 
Colon, cancer of, 533; dilatation of, 545. 
Coloptosis, 543. 

Coma, diabetic, 425; epileptic, 1096; from 
heat-stroke, 396; from muscular exertion, 
869; in acute encephalitis, 1025; in acute 
yellow atrophy, 552; in alcoholic poisoning, 
380; in apoplexy, 1001; in cerebral syphilis, 
246; in general paresis, 962; in multiple 
sclerosis, 960; in pernicious malaria. 215; 
in thrombosis of cerebral sinuses, 1015; in 
typhoid fever, 29; uraemic, 867. 

Coma vigil, 29. 

Comatose form of malaria, 215. 
Comma bacillus, 175. 
Common bile-duct, obstruction of, 560. 
Compensation in valve lesions, 708; periods 
In, 740; rupture of, 741. 



Composite portraiture in tuberculosis, 268. 

Compressed air disease, 969. 

Compression and traction of the bowel, 

533. 

Compression paraplegia, 970. 
Concretions (see Calcareous). 
Concussion of spinal cord, 1133. 
Confusional insanity, 30. 
Congenital heart affections, 765. 
Congenital stenosis of pylorus, 494. 
Congenital stricture of the bowel, 533. 
Congenital syphilis, 242. 

Conjugate deviation in brain tumor, 1023; in 
apoplexy, 1002; in tuberculous meningitis, 
279. 

Conjunctiva, diphtheria of, 149. 

Consecutive nephritis, 886. 

Constipation, 538; in adults, 538; in infants, 
540; spasmodic, 539; treatment of, 540. 

Constitutional diseases, 399. 

Consumption (see Tuberculosis). 

Contracted kidneys, 877. 

Contracture, hysterical, 1114; in hemiplegia, 
1005; of nursing women, 1110. 

Contusion pneumonia, 109. 

Conus arteriosus, stenosis of, 767. 

Conus medullaris, lesions of, 972. 

Convalescence, fever of, 16; from typhoid 
fever, management of, 47. 

Convulsions, epileptic, 1096; hysterical, 1112; 
in acute yellow atrophy, 552; in alcoholism, 
380; in aspiration of pleural effusion, 678; 
in cerebral haemorrhage, 1001; in cerebral 
syphilis, 246, 1099; in cerebral tumors, 
1021; in chronic Bright's disease, 876. 

Convulsions, infantile, 1091; relation to 
rickets, 438. 

Convulsions, in general paralysis, 962; in he- 
patic colic, 564; in infantile hemiplegia, 
1019; in lead-poisoning, 389; in meningitis, 
955; in sun-stroke, 397; in typhoid fever, 
29; in uraemia, 866; Jacksonian, 1098. 

Convulsive tic, 1088. 

Coordination, disturbance of, in tabes, 923. 

Copaiba eruption, 88. 

Copper test for sugar, 423. 

Copraemia, 539, 792. 

Coprolalia, 1089. 

Cor adiposum, 749. 

Cor triloculare, 766. 

Cor bovinum, 711. 

Cor villosum, 689. 

Coronary arteries, in angina pectoris, 762, 

763; obliteration of. 747. 
Corpora quadrigemina, tumors in, 1023; 

lesions of, 984. 
Corpulence, 439. 

Corpus callosum, lesions of, 981. 
Corrigan'a disease. 709. 
Corrigan pulse, 714. 



1158 



INDEX. 



Coryza, acute, 610; foetida, 612; from the io- 
dides, 254. 
Costiveness, 538. 

Cough, barking, of puberty, 1117; hysterical, 
1116; in acute bronchitis, 622; in chronic 
bronchitis, 624; in pertussis, 93; in 
phthisis, 300; during aspiration of pleural 
effusion, 677; in pneumonia, 118; paroxys- 
mal, in bronchiectasis, 627; paroxysmal, in 
fibroid phthisis, 314; stomach, 469. 

Coup de soleil, 395. 

Cow-pox, 68. 

Cracked-pot sound, 309. 

Cramp, writer's, 1107. 

Cramps, in cholera,™ 180; in gout, 415; in 

chronic Bright's disease, 882. 
Cranio-sclerosis, 437. 

Cranio-tabes, relation to congenital syphilis, 

436; in rickets, 436. 
Craw-craw, 361. 
Creophila, 378. 

Cretinism, endemic, 840; sporadic, 840. 
Cretinoid change, 840. 

Crises, gastro-intestinal, in angio-neurotic 
cedema, 1140; in locomotor ataxia, 924; in 
purpura, 816; nasal, in tabes, 925. 

Crisis, in pneumonia, 117; in relapsing fever, 
54; in typhus fever, 51. 

Crossed or alternating paralysis, 984, 1004. 

Crossed sensory paralysis, 985. 

Croup, membranous, 148; spasmodic, 617. 

Croupous enteritis, 512. 

Croupous pneumonia, 108. 

Crura cerebri, lesions of, 983, 1004. 

Crutch paralysis, 1070. 

CruveWiier's palsy, 929. 

Cry, epileptic, 1096; hydrocephalic, 278; hys- 
terical, 1116; in congenital syphilis, 243. 

Cryptogenetic septicaemia, 162. 

Cur&chmanri 's spirals, 631, 633. 

Cyanosis, in acute tuberculosis, 276; in con- 
genital heart-disease, 768; in emphysema, 
657. 

Cyeloplegia, 1047. 

Cynanche maligna, 138. 

Cynobex hebetica, 1117. 

Cystic disease, of kidney, 898; of liver, 584. 

Cystic duct, obstruction of, 565. 

Cysticercus cellulosse, 368; ocular, 369; sub- 
cutaneous, 369; general, 369; cerebro- 
spinal, 369. 

Cystine calculi, 862, 892. 

Cystinuria, 861. 

Cystitis, in locomotor ataxia, 925; in trans- 
verse myelitis, 978; tuberculous, 326. 
Cytozoa, 349. 

Cysts, chylous, of mesentery, 547; in kid- 
neys, 898; of brain, 1021; porencephalic, 
1017; of brain, thrombotic, 1009; pan- 
creatic, 592. 



Dacryoadenitis (see Lachrymal Glands). 

Dancing mania, 1088. 

Dandy fever (dengue), 99. 

Davainea Madagascariensis, 366. 

Day-blindness, 1040; in scurvy, 824. 

Deaf-mutism after cerebro-spinal fever, 106. 

Deafness, in cerebral tumor, 1023; in cere- 
bro-spinal meningitis, 106; in hysteria, 
1116; in M^mere's disease, 1058; in scarlet 
fever, 81; in tabes dorsalis, 924; nervous, 
1057. 

Death, modes of, in tuberculosis, 317; sud- 
den, in angina pectoris, 762; in aortic in- 
sufficiency, 712; in typhoid fever, 40; in 
pleural effusion, 671. 

Debility, nervous (see Neurasthenia), 1122. 

Decubitus, acute, 1002; (bed-sores) in trans- 
verse myelitis, 978. 

Degeneration, reaction of, 914; in neuritis, 
1036; in facial paralysis, 1054. 

Deglutition, difficult (see Dysphagia). 

Deglutition pneumonia, 642. 

Delayed resolution in pneumonia, 129. 

Delayed sensation in tabes, 924. 

Delirium, acute, 1075; acute, in lead-poison- 
ing, 389; cordis, 40, 755, 757; expansive, 
962; in acute rheumatism, 171; in pneu- 
monia, 122; in typhoid fever, 28; in typhus 
fever, 52; tremens, 382. 

Deltoid, paralysis of, 1070. 

Delusional insanity after pneumonia, 123. 

Delusions of grandeur, 962. 

Dementia paralytica, 960; alcohol as a fac- 
tor in, 381; syphilis and, 242, 246, 961. 

Demodex folliculorum, 376. 

Dengue, 99. 

Dentition, in congenital syphilis, 243; in 
mercurial stomatitis, 445; in rickets, 437. 

Dercum's disease, 440. 

Dermacentor americanus, 376. 

Dermatitis, exfoliative form, 82. 

Dermatobia, 378. 

Dermato-myositis, 1148. 

Dermatose parasitaire, 361. 

Desquamation, in measles, 87; in rubella, 89; 
in scarlet fever, 79; in small-pox, 62; in 
typhoid fever, 17. 

Deviation, secondary, 1048. 

Devonshire colic, 386. 

Dextrocardia, 765. 

Diabetes insipidus, 432; heredity in, 432; in 
abdominal tumor, 432; in tuberculous peri- 
tonitis, 432. 

Diabetes mellitus, 418; acute form, 422; 
bronzing in, 425; chronic form, 422; coma 
in, 425; diet in, 428; dietetic form, 422; 
gangrene in, 425; hereditary influences in, 
418; in obesity, 419; in children, 425: lipo- 
genic form, 422; neurotic form. 422; 
pancreas in, 421; pancreatic form, 422; 



INDEX. 



1159 



paraplegia in, 427; perforating ulcer in, 
425; theories of, 420; urine in, 423. 

Diabetes, phosphatic, 862. 

Diabetic, centre in medulla, 419; cirrhosis, 
421; coma, 425; phthisis, 421; tabes, 426. 

Diacetic acid, 864. 

Diaphragm, paralysis of, 1068; degeneration 
of muscle of, 1068. 

Diarrhoea, 505; acute dyspeptic, 509; alba, 
511; bacteria in, 508; chronic treatment of, 
514; chylosa, 511; endemic, of hot coun- 
tries, 364; from anchylostomiasis, 360; in 
children, treatment of, 516; in cholera, 179; 
in dysentery, 198, 200; in hysteria, 1117; 
in phthisis, 311; in typhoid fever, 23; in 
uraemia, 867; nervous, 506; of Cochin- 
China, 365; tubular, 544; lienteric, 507. 

Diathesis, gouty, 408, 414; haemorrhagic, 
814; lithic acid, 859; tuberculous or scrofu- 
lous, 268; uric acid, 860. 

Diazo-reaction in typhoid fever, 30. 

Dicrotism of pulse in typhoid fever, 13, 19. 

Diet, in chronic dyspepsia, 470; in constipa- 
tion, 540; in convalescence from typhoid 
fever, 47; in diabetes, 428; in gout, 416; in 
infantile diarrhoea, 516; in obesity, 439; in 
scurvy, 822; in tuberculosis, 335; in ty- 
phoid fever, 42. 

Dietl's crises, 848. 

Digestive system, diseases of, 441. 

Dioctophyme gigas, 364. 

Diphtheria, 138; atypical forms of, 146; of 
auditory meatus, 149; of conjunctiva, 149; 
and croup, 144; bacillus of, 140; contagious- 
ness of, 138; hemiplegia in, 150; immunity 
from, 141; in animals, 139; laryngeal, 148; 
latent, 147; nephritis in, 150; neuritis in, 
151; nasal, 147; pharyngeal, 146; of skin, 
149; symptoms of, 146; systemic infection, 
147; antitoxine treatment of, 155; of 
wounds, 149. 

Diphtheritic, colitis, 512; membrane, his- 
tology of, 144; processes in pneumonia, 
115; processes in typhoid fever, 33. 

Diphtheritis, 142. 

Diphtheroid inflammations, 142. 

Diplegia, facial, 1053; in children, 938. 

Diplococcus intracellularis meningitidis, 102. 

Diplococcus pneumoniae (micrococcus lanceo- 
latus, pneumococcus), 110; in empyema, 
671; in endocarditis, 702; in peritonitis, 597. 

Diplopia (see Double Vision), 1049. 

Dipsomania, 380. 

Dipylidium caninum, 366. 

Disinfection, in diphtheria, 153; in typhoid 
fever, 410. 

Dissecting aneurism, 776. 

Distomiasis, 351. 

Distomum lanceolatum, 351; D. buski, 351; 
D. endemicum, 351; D. perniciosum, 351; 



D. sinense, 351; D. felineum, 351; D. wes- 

termanni, 638, 352. 
Dittrich's plugs, 625. 
Diuresis, 432. 
Diver's paralysis, 969. 
Diverticula of oesophagus, 462. 
Dochmius duodenalis, 359. 
Dorsodynia, 407. 
Dothienenterite, 1. 
Double heart, 765. 

Double vision, 1049; in ataxia, 922; in 
chronic Bright' s disease, 881. 

Dracontiasis, 362. 

Dracunculus medinensis, 362. 

Drainage and diphtheria, 138; and scarlet 
fever, 76; and tonsillitis, 451; and typhoid 
fever, 5. 

Dreamy state in epilepsy, 1097. 

Dropsy, cardiac, treatment of, 733; in 
anaemia (oedema), 797 ; in acute Bright's 
disease, 870; in aortic insufficiency, 712; 
in aortic stenosis, 717; in cancer of 
stomach, 490; in chronic Bright's disease, 
876; in mitral insufficiency, 720; in mitral 
stenosis, 725; in phthisis, 312; in scarlet 
fever, 80. 

Drug-rashes, 83, 814. 

Drunkenness, diagnosis from apoplexy, 380, 

1007. 
Dry mouth, 447. 

Dulness, movable, in pleural effusion, 669; 

in pneumothorax, 683. 
Dumb ague, 217. 

Duodenal ulcer,. 478; diagnosis of, from gas- 
tric, 484. 

Duodenum, defect of, 533; ulcer of, 478. 
Dura mater, diseases of, 951; haematoma of, 
952. 

Durande's mixture, 568. 
Duroziez's murmur, 714. 

Dust, diseases due to, 650, 652; tubercle 

bacilli in, 261. 
Dysacusis, 1057. 

Dysentery, 193; abscess of liver in. 196, 200; 
acute catarrhal, 198; acute specific, 193; 
amoeba coli in, 195; chronic, 199; diph- 
theritic, 199; treatment of, 201; tropical or 
amoebic, 195. 

Dyspepsia, acute, 463; chronic, 466; nervous, 
497. 

Dysphagia, hysterical. 1117: in cancer of the 
oesophagus, 461; In hydrophobia, 228; in 
cesophagismus. 4.1!); in oesophagitis, 45S; in 
pericardial effusion, 692; in thoracic aneu- 
rism, 781; in tuberculous laryngitis. <;1!>. 

Dyspnoea, cardiac, treatment of, 7:?:>: from 
aneurism, 781; hysterical, inc. 1183; in 
acute tuberculosis, 275; in aortic insuffi- 
ciency, 712; in cardiac dilatation. T 4 1 : in 
chlorosis, 792; in diabetic coma. 426; in 



1160 



INDEX. 



mitral insufficiency, 719; in mitral steno- 
sis, 725; in pericardial effusion, 692; in 
pneumonia, 117; in phthisis, 304; in 
cedema of the glottis. 617: in spasmodic 
laryngitis, 618; uraernic, 867. 
Dystrophies, muscular, 933; clinical forms 
of, 934. 

Ear, complications of scarlet fever, 81; affec- 
tions of, in syphilis, 241, 244: symptoms 
simulating meningitis, 955. 1027. 

Ebstein's method in obesity, 439. 

Echinococcus cyst, fluid of. 371, 373. 

Echinococcus disease, 370. 

Echinococcus, endogenous, 371; exogenous, 
371; multilocular, 371, 374. 

Echinorhynchus, gigas; E. moniliformis. 365. 

Echokinesis, 1089. 

Echolalia, 1089. 

Eclampsia, 1091: nutans. 1089. 

Ectopia cordis, 765. 

Eczema of the tongue, 445: in diabetes, 425; 
in gout, 414. 

Efferent tract, diseases of. 928. 

Ehrlich's reaction in typhoid fever, 30. 

Elastic tissue in sputum. 301. 

Electrical reactions, in exophthalmic goitre, 
839; in facial palsy. 1054; in Landry's 
paralysis. 947: in multiple neuritis. 1036; 
in periodical paralysis, 1136; in polio- 
myelitis anterior, 944; in Tlwmscn's dis- 
ease, 1149. 

Electrolysis in aneurism, 785. 

Elephantiasis, 362. 

Emaciation, in anorexia nervosa, 1117: in 
gastric cancer, 489: in oesophageal cancer, 
461; in phthisis, 306. 

Embolic abscesses, 164. 

Embolism, 'and aneurism, 776; in chorea, 
1082; in typhoid fever, 21: of cerebral ar- - 
teries. 1008. 

Embryocardia, 757; in pneumonia, 120; in 
typhoid fever, 20. 

Emphysema, 654; acute vesicular, 660; 
atrophic, 659; compensatory, 655; hyper- 
trophic. 655; interstitial, 660. 

Emphysema, subcutaneous, after trache- 
otomy, 687; after aspiration of the pleura, 
677; in gastric ulcer, 479; in phthisis, 313; 
of the mediastinum, 687. 

Emprosthotonos in tetanus, 232. 

Empyema, 671; bacteriology of, 671: necessi- 
tatis, 237, 672, 783; perforation of lung in, 
673. 

Encephalitis, acute, 1024; meningo-. chronic 
diffuse. 960; meningo-, fcetal, 938; polio-, 
of Striimpell, 1018; suppurative, 1025; 
syphilitic, 245. 

Encephalopathy, lead, 388. 

Euchondroma of lung, 663. 



Endarteritis of spinal cord, 967. 

Endocarditis, acute, 698; chronic, 705; 
chronic vegetative, 701; diphtheritic, 699; 
in chorea, 699, 1084; infectious, 699; in the 
foetus, 707, 767; gonorrhoea^ 256: in pneu- 
monia, 700; in puerperal fever, 700; in 
rheumatism, 170, 699; in septicaemia, 700; 
in typhoid fever, 12, 21; in tuberculosis, 
298, 700; malignant, 699; meningitis in. 
700; micro-organisms in, 702; mural, 701; 
recurring, 699; sclerotic, 707; simple or 
verrucose, 699, syphilitic, 250; ulcerative, 
699. 

Endophlebitis, 774. 

Enteric fever (see Typhoid Fever), 1. 

Enteritis, catarrhal, 505: croupous. 512, 
diphtheritic, 512; in children, 508; phleg- 
monous, 512; membranous or tubular, 544; 
ulcerative, 512. 

Entero-colitis, acute, 510. 

Enteroclysis in cholera, 181. 

Enteroliths, 519, 534: as a cause of appendi- 
citis, 519; in sacculi of colon, 539. 

Enteroptosis. 541. 847. 1126. 

Entozoa (see Axmal Parasites), 349. 

Eosinophilia in leukaemia, 806; in trichinosis, 
357. 

Ependymitis. purulent, 277. 

Ephemeral fever, 342. 

Epidemic hseinoglobinuria, 818, 853. 

Epidemic roseola, 89. 

Epidemic stomatitis, 347. 

Epididymitis (see Orchitis), 251, 326. 

Epilepsia, larvata, 1098; nutans, 1066. 

Epilepsy, 1093; and alcoholism, 1095: and 
syphilis, 1095, 1099; heredity in, 1094; in 
chronic ergotism, 394; in general paresis. 
962; in lead-poisoning, 389; in Raynaud's 
disease, 1139; Jacksonian, 917, 1098; 
masked, 1098; post-epileptic symptoms of, 
1097; procursive. 1096; reflex, 1095; rota- 
tory, 1096; spinal, 937: surgical treatment 
of. 1101. 

Epileptic fits, stages of. 1096. 

Epistaxis, 614; in haemophilia, 820: in 
scurvy, 823; in typhoid fever, 27: " renal." 
S52: vicarious, 614. 

Erb-Goldflam's symptom-complex, 947. 

Erb's syphilitic spinal paralysis, 940. 

Ergotism, 394; convulsive, 394; gangrenous. 
394. 

Erosion of teeth, 445. 
Eructations, nervous. 498. 
Eruptions (see Rashes). 

Erysipelas, 157; abscess in, 159: after vacci- 
nation, 71: facial, 158; in typhoid fever, 33; 
migrans, 159; puerperal, 157. 

Erythema, exudativum. S15: in pellagra. 
395; in typhoid fever, 17; in tonsillitis, 452. 

Erythromelalgia, 1106, 1139. 



INDEX. 



1161 



Eschar, sloughing, in hemiplegia, 1002. 

Eustrongylus gigas, 364. 

Exaltation of ideas in general paresis, 962. 

Exanthematous typhus, 49. 

Exfoliative dermatitis, 82. 

Exophthalmic goitre, 836; acute form, 837; 
diminution of electrical resistance in, 839; 
pigmentation in, 839; tremor in, 839; urti- 
caria in, 839. 

Eye, motor nerves of, paralysis of, 1046; 
spasm of, 1047. 

Eye-strain in migraine, 1102. 

Eyes, conjugate deviation of, in brain tumor, 
1023; in apoplexy, 1002; in tuberculous 
meningitis, 279. 

Facial, asymmetry, 1064, 1141; diplegia, 
1053; hemiatrophy, 1141; hemihypertrophy, 
1142; nerve, paralysis of, 1051; paralysis 
from cold, 1053; paralysis from lesion of 
trunk of nerve, 1052; paralysis from lesion 
of cortex, 1052; paralysis, symptoms of, 
1053. 

Facial spasm, 1055. 

Facies, Hippocratic, 598; leontina, in leprosy, 
341; in mouth-breathers, 455; Parkin- 
sonian, 1077; syphilitic, 243; in typhoid 
fever, 14. 

Faecal, accumulation, 534, 539; concretions, 

519, 539; vomiting, 534. 
Faeces, bacteria in, 508; in jaundice, 549. 
Fallopian tubes, tuberculosis of, 326. 
Famine fever (see Relapsing Fever), 53. 
Farcy, 233; acute, 234; chronic, 235. 
Farcy-buds, 234. 
Farre's tubercles, 583. 
Fasciola hepatica, 351. 
Fat embolism in diabetes, 426. 
Fat necrosis, 591; of pancreas, in diabetes, 

422. 

Fatty degeneration, of arteries, 770; of kid- 
neys, 874; of liver, 585; of the new-born 
(Buhl's disease), 818. 

Fatty degeneration of heart, 749; in anaemia, 
796. 

Fatty stools, 590. 
Febricula, 342. 

Febris, carnis, 48; recurrens, 53. 
Fchling's test for sugar, 423. 
Fermentation, test for sugar, 424. 
Fetid stomatitis, 442. 

Fever, aphthous, 347; in cholera, 179; entero- 
mesenteric, 1; ephemeral, 342; gastric, 463; 
glandular, 345; hysterical; 1119; pernicious 
malarial, 215; in pneumonia, 116; in acute 
pneumonic phthisis, 290, 293; in acute 
miliary tuberculosis, 274; in primary mul- 
tiple neuritis, 1033; in meningitic tuber- 
culosis, 278; in pulmonary tuberculosis, 
304; in pyaemia, 164; in pylephlebitis, sup- 



purative, 580; in intermittent fever, 212; 
in relapsing fever, 54; in remittent fever, 
213; in scarlet fever, 77; in septicaemia, 
162; in small-pox, 59; in sun-stroke, 396; 
in appendicitis, 524; in secondary syphilis, 
240; in typhoid fever, 14; in yellow fever, 
185; lung, 108; Malta, 219; Mediterranean, 
219; mountain, 346; Neapolitan, 219; putrid 
malignant, 1; relapsing, 53; rock, 219; ship, 
49; slow nervous, 1; splenic, 224; spotted, 
49, 101; typhoid, 1; typho-malarial, 39, 214; 
typhus, 49; undulant, 219; yellow, 182. 

Fever, idiopathic intermittent, 163. 

Fever, intermittent, in abscess of liver, 579; 
in ague, 212; in chronic obstruction of bile- 
passages by gall-stones, 566; in Hodgkin's 
disease, 812; in pyaemia, 164; in pyelitis, 
888; in septicaemia, 163; in secondary 
syphilis, 240; in tuberculosis, 299, 305. 

Fibrinous, bronchitis, 632; pneumonia, 108. 

Fibroid disease of heart, 747. 

Fibrosis, arterio-capillary, 770. 

Fievre, inflammatoire, 397; typho'idc a -forme 
renale, 31. 

Fifth nerve, paralysis of, 1050; gustatory 
branch, 1051; trophic changes in paralysis 
of, 1050. 

Filaria hominis sanguinis, F. bancrofti, F. 
diurna, F. perstans, 360; F. medinensis, 
362. 

Filaria loa, F. lentis, F. labialis, F. hominis 
oris, F. bronchialis, F. immitis, 364. 

Filariasis, 360. 

Fish, poisoning by, 393. 

Fisher's brain murmur, 437. 

Fistula in ano in tuberculosis, 315, 320. 

Fistula, cesophago-pleuro-cutaneous, 462. 

Flatulence, in hysteria, 1117; in nervous dys- 
pepsia, 500; treatment of, 473. 

Flea, bite of, 378. 

Flint's murmur, 713, 724. 

Floating kidney, 542, 846. 

Florida fever, 397. 

Fluke, bronchial, 352; blood, 352; liver, 
351. 

Flukes, diseases caused by, 351. 

Foetal heart-rhythm, 757. 

Foetus, endocarditis in, 767; syphilis in, 242; 

tuberculosis in, 262; white pneumonia of, 

247; typhoid fever in, 35. 
Folic Brightique, 866. 
Follicular tonsillitis, 451. 
Food (see Diet). 
Food poisoning, 391. 
Foot and month disease, 347. 
Foreign bodies In intestines, 5:54. 
" Fourth disease," 90. 
Fourth nerve, 1047; paralysis of, 1047. 
Fremitus, vocal, lit), 307; hydatid. 372. 
Friction, mediastinal, 687; pericardial, 690; 



1162 



INDEX. 



peritoneal, 604; pleural, 308, 670; pleuro- 
pericardial, 308. 
Friedreich's ataxia, 949. 

Friedreich's sign in adherent pericardium, 
697. 

Frontal convolutions, lesions of, 1022. 
Frontal sinuses, pentastomes in, 375. 
Funnel breast, 307, 455. 

Gait, ataxic, 923; in paralysis agitans, 1077; 
in pseudohypertrophic muscular paraly- 
sis, 934; in spastic paraplegia, 937; pseudo- 
tabetic, 426, 1034; steppage, in peripheral 
neuritis, 1034; in diabetic tabes, 426. 

Galactotoxismus, 393. 

Gall-bladder, diseases of, 555; atrophy of, 
566; calcification of, 565; dilatation of, 565; 
empyema of, 565; forming abdominal 
tumor, 565; phlegmonous inflammation of, 
565. 

Gallop-rhythm, 757. 

Galloping consumption, 292. 

Gall-stone crepitus, 565. 

Gall-stones, 561. 

Game-birds, poisoning by, 393. 

Ganglia, basal, tumors of, 1022. 

Gangrene, in diabetes, 425; in ergotism, 394; 
in pneumonia, 130; in typhoid fever, 12, 
22; in typhus, 52; local or symmetrical, 
1138; multiple, 1138; of lung, 660; of 
mouth, 444. 

Gangrenous stomatitis, 444. 

Garrod's thread test for uric acid, 410. 

Gas-bacillus (see Bacillus aerogenes cap- 

SULATUS). 

Gastralgia, 501. 

Gastrectasis, 474. 

Gastric catarrh, acute, 463. 

Gastric, crises, 484, 501, 924; fever, 463. 

Gastric juice, hyperacidity of, 484, 500; sub- 
acidity of, 501. 

Gastric spasm, congenital, 495. 

Gastric ulcer, 478; clinical forms of, 482. 

Gastritis, acute, 463; acute suppurative, 464; 
chronic, 466; diphtheritic, 465; membra- 
nous, 465; mycotic, 466; parasitic, 466; 
phlegmonous, 464; polyposa, 467; sclerotic, 
467; simple, 463; simple chronic, 466; toxic, 
465. 

Gastrodynia, 501. 
Gastrorrhagia, 495. 
Gastrotomy, 462. 
Gastroxynsis, 500. 

General paralysis of the insane (general par- 
esis), 960; diagnosis of, from syphilis, 246, 
963; influence of syphilis in, 242, 246, 961. 

Genito-urinary system, tuberculosis of, 322. 

Gentles, 379. 

Geographical tongue, 445. 
Gerlier's disease, 1059. 



German measles, 89. 
Giant growth, 1143. 
Giants and gigantism, 1143. 
Gigantism and acromegaly, 1143. 
Gigantoblasts, 799. 
Gigantorhynchus gigas, 365. 
Gilles de la Tourette's disease, 1089. 
Gin-drinker's liver (see Cirrhosis of Liver), 
569. 

Glanders, 233; acute, 234; chronic, 234; diag- 
nosis from small-pox, 66. 

Glandular fever, 345. 

Glenard's disease, 541. 

Glioma of brain, 1020. 

Gliosis, 975. 

Globulin in urine, 857. 

Globus hystericus, 1112. 

Glomerulo-nephritis, 870. 

Glosso-labio-laryngeal paralysis, 932. 

Glosso-pharyngeal nerve, affections of, 1059. 

Glossy skin in arthritis deformans, 402. 

Glottis, oedema of, 617; in Bright's disease, 
881; in small-pox, 64; in typhoid fever, 11. 

Gluteal nerve, affections of, 1072. 

Glycogen, formation of, 420. 

Glycogenic function of liver, 420. 

Glycosuria, 420, 865; gouty, 415; lipogenic, 
422. 

Gmelin's test, 549. 

Goitre, 835; exophthalmic, 836; sudden 
death in, 836. 

Gonorrhoeal arthritis, 256; endocarditis, 256; 
septicaemia and pyaemia, 255. 

Gonorrhoeal infection, 255; systemic, 255. 

Gout, 407; acute, 411; chronic, 413; Ebstein's 
theory of, 409; hereditary influence in, 408; 
influence of alcohol in, 408; influence of 
food in, 408; influence of lead in, 408; ir- 
regular, 414; nervous theory of, 409; retro- 
cedent or suppressed, 413. 

Gouty kidney, 877. 

von Graefe's sign, 838. 

Grain, poisoning by, 394. 

Grandeur, delusions of, 962. 

Grand mal, 1094, 1095. 

Granular kidney, 877. 

Granulomata, infectious, of brain, 1020. 

Gravel, renal, 892. 

Graves' disease, 836. 

Green cancer, 809. 

Green-sickness (see Chlorosis), 792. 
Green-stick fracture in rickets, 437. 
Gregarinidse, parasitic, 349. 
Grinder's rot, 652. 
Grippe, la, 95. 
Gruellcr's tumor, 388. 
Guinea-worm disease, 362. 
Gull's disease, 841. 

Gummata, 239; in acquired syphilis, 241; in 
congenital syphilis, 244; of brain and spinal 



INDEX. 



1163 



cord, 244; of heart, 250; of kidneys, 250; of 
liver, 248; of lungs, 247; of rectum, 249; of 
testis, 251; structure of, 239. 

Gummatous periarteritis, 250. 

Gums, black line on, in miners, 387; blue line 
on, in lead-poisoning, 387; in scurvy, 823; 
in stomatitis, 442; red line on, in pul- 
monary tuberculosis, 311. 

Gustatory paralysis, 1051. 

Habit spasm, 1088; in mouth-breathers, 456. 

Habitus, apoplectic, 998; phthisicus, 268. 

Haeinateinesis, 495; causes of, 495; in cir- 
rhosis of liver, 572; diagnosis from hae- 
moptysis, 497; in enlarged spleen, 216, 495; 
in scurvy, 823; in typhoid fever, 23. 

Haemato-chyluria, non-parasitic, 859; para- 
sitic, 361. 

Hsematoma of dura, of brain, 952; of cord, 

953; of mesentery, 546. 
Haematomyelia, 968. 
Haeinatoporphyrin, 865. 
Haeinatorrhachis, 967. 

Haematuria, 851; endemic, of Egypt, 352; in 
acute nephritis, 870; in chronic phthisis, 
312; in psorospermiasis, 350; in renal cal- 
culus, 894; in renal cancer, 897; in tuber- 
culosis of kidney, 325; malaria, 216. 

Haemochroniatosis, 421. 

Hsemocytozoa of malaria, 204. 

Haemoglobin, rediiction of, in chlorosis, 793. 

Haeinoglobinaeinia, 854. 

Haeinoglobinuria, 852; epidemic, in infants, 
243, 818, 853; in Raynaud's disease, 1138; 
paroxysmal, 853; toxic, 853. 

Haemoglobinuric fever, 216. 

Haemo-pericardium, 698. 

Haerno-peritoneum, 588. 

Haemophilia, 819. 

Haemoptysis, causes of, 637; hysterical, 1117; 
at onset of phthisis, 299; in acute broncho- 
pneumonic phthisis, 293; in acute miliary 
tuberculosis, 275; in aneurism, 637, 781; in 
aortic insufficiency, 712; in arthritic sub- 
jects, 638; in bronchiectasis, 627; in cir- 
rhosis of lung, 651; in emphysema, 659; 
in mitral insufficiency, 720; in mitral ste- 
nosis, 725; in pneumonia, 118; in pulmo- 
nary gangrene, 662; in scurvy, 823; spuri- 
ous, 1117; symptoms of, 638; treatment of, 
639; in typhoid fever, 28; relation to tuber- 
culosis, 637; parasitic, 352; periodic, 637; 
vicarious, 637. 

Haemorrhage, broncho-pulmonary, 637; cere- 
bral, 997; from mesentery, 546; from the 
stomach, 495; in acute yellow atrophy, 552; 
in anaemia, 799; in cirrhosis of the liver, 
572; in contracted kidney, 8S2; in gastric 
cancer, 490; in gastric ulcer, 481; in 
haemophilia, 820; in hysteria, 1117, 1118: 



in intussusception, 537; in leukaemia, 805; 
in malaria, 216; in nephrolithiasis, 894; in 
the new-born, 818; in purpura haemor- 
rhagica, 816; in scarlet fever, 79; in scurvy, 
823; in small-pox, 62; in splenic enlarge- 
ment, 216, 495; into pancreas, 588; into 
spinal cord, 968; into spinal membranes, 
967; in tuberculous pyelitis, 325; in tuber- 
culosis of bowels, 319; into ventricles of 
brain, 999; in typhoid fever, 10, 23; in yel- 
low fever, 186; pulmonary, 302, 637. 

Haemorrhagic diathesis, 814. 

Haemorrhagic diseases of the new-born, 818. 

Haemorrhagic typhoid fever, 34. 

Haemothorax, 674. 

Hair tumors in stomach, 494. 

Hallucinations in hysteria, 1119. 

Harrison's groove in rickets, 436; in en- 
larged tonsils, 455. 

Harvest-bug, 376. 

Hay-asthma (hay- fever), 612. 

HaygartWs nodosities, 401. 

Headache, from cerbral tumor, 1021; in cere- 
bral syphilis, 246; in mouth-breathers, 456; 
in typhoid fever, 13, 14, 28; in uraemia, 867; 
sick, 1102. 

Head-cheese, poisoning by, 391. 

Head-shaking in infants, 1066. 

Heart, diseases of, 698; diseases of, OerteVs 
treatment of, 752; amyloid degeneration of, 
750; aneurism of, 753; athlete's, 710; brown 
atrophy of, 750; calcareous degeneration 
of, 750; congenital affections of, 765; dila- 
tation of, 741; displacement in pleuritic 
effusion, 667; displacement in pneumo- 
thorax, 682; fatty disease of, 749; foreign 
bodies in, 754; fragmentation of fibres of, 
748; hydatids of, 754; hypertrophy of, 735; 
hypertrophy of, in Bright's disease, 880; in 
exophthalmic goitre, 838; irritable, 74.", 
756; new growths in, 754; neuroses of, 755; 
palpitation of, 755; parenchymatous de- 
generation of, 748; rupture of, 753; tubercle 
of, 754; tumors of, 754; valvular diseases 
of, 707; wounds of, 754. 

Heart-muscle in fevers, 748. 

Hoart-sounds, weakness of, 744; increased 
loudness of, 739; audible at distance, 724, 
838. 

Heart-valves, congenital anomalies and 

lesions of, 766; rupture of, 711. 
Heat, exhaustion, 395; stroke, 395. 
Heherden's nodes, 401. 
Hectic fever, 306. 
Heel, painful. 1106. 
Heller' 8 test, 856. 

Helminthiasis (see Animal Takasites), 349. 
Hemeralopia, 1040; in scurvy, 824. 
Hemlalbumose, 857. 

Hemianesthesia, in cerebral haemorrhage, 



1161 



INDEX. 



1005; in hysteria, 1115: in lesions of inter- 
nal capsule, 983; in unilateral cord lesions, 
965. 

Hemianopia, heteronymous, 1042; homony- 
mous, 1042; in migraine, 1102; lateral, 
1042; nasal, 1042; significance of, 1045; 
temporal, 1042. 

Hemicrania, 1102. 

Hemiopic pupillary inaction, 1044. 

Hemiplegia, 1002; crossed, 984, 1004. 

Hemiplegia, infantile, 1017: aphasia in. 1018; 
in diphtheria, 150; epilepsy in, 1019; in hys- 
teria, 1114; mental defects in, 101S; post- 
hemiplegic movements in, 1019; spastica 
cerebralis. 1018; in typhoid fever, 30. 

Hemiplegie flasque, 1006. 

Henoch's purpura, 816. 

Hepatic abscess, 577; artery, enlargement 

of, 555: colic. 563; intermittent fever, 566; 

vein, affections of, 555. 
Hepatitis, diffuse syphilitic, 248: interstitial 

(see Cirrhosis), 569; suppurative, 577. 
Hepatization, of lung, 113; white, of foetus, 

247. 

Hereditary form of oedema, 1141. 

Heredity, in Bright's disease. 877; in dia- 
betes insipidus, 432; in Friedreich's ataxia, 
949; in gout, 408; in haemophilia, 819; in 
paramyoclonus multiplex, 1150; in spastic 
paraplegia, 940; in syphilis, 23S; in tuber- 
culosis, 262. 

Herpes, in trifacial neuralgia, 1105; in 
cerebro-spinal meningitis, 104; in febric- 
ula. 343; in malaria, 212; in pneumonia, 
122: in typhoid fever, 17; zoster, 1106. 

Hiccough, 106S; causes of, 1068; treatment 
of. 1069; hysterical, 1116. 

High-tension pulse, characters of, 774, 880. 

Hippocratic facies, 598; fingers, 313; succus- 
sion, 683. 

Hippus. 1102. 

Hodgkin's disease, 809; intermittent fever in, 
812. 

Homalomyia scalaris, 378. 

Horn-pox. 63. 

Hospital fever, 49. 

Huntingdon's chorea, 1090. 

Husband and wife, diabetes in, 418; tuber- 
culosis in, 266. 

Hutchinson's teeth, 243. 

Hyaline casts in urine, 871, 876, 880. 

Hybrid measles, S9. 

Hydatid disease (see Ecmxococcus). 

Hydatid thrill or fremitus, 372. 

Hydrarthrosis, chronic, 257; intermittent, 
1118. 

" Hydrencephaloid condition,'* 510, 996. 
Hydriatic treatment (see Hydrotherapy). 
Hydrocephalus, 1028; acquired chronic, 1029; 
acute, 276, 1028; angio-neurotic, 1028; 



chronic, after cerebro-spinal meningitis, 
106; congenital, 1029; idiopathic internal, 
1028; spurious, 510. 
Hydromyelus, 953, 975. 

Hydronephrosis, 889; congenital, 889; inter- 
mittent, S4S, 890. 
Hydropericardium, 697. 
Hydroperitonaeum, 605. 
Hydrophobia, 227. 
Hydro-pneumothorax, 681. 
Hydrops vesicae fellae, 565. 
Hydro thorax, 680. 

Hymenolepsis diminuta; H. nana, 366. 
Hyperacidity, 500. 
Hyperacusis, 1057. 

Hyperaesthesia. in ataxia, 924; in hysteria, 
1115; in rickets, 435; in unilateral cord 
lesions, 965. 

Hyperchlorhydria, 500. 

Hyperosmia, 1038. 

Hyperpyrexia, hysterical, 1120; in rheumatic 
fever, 170: in scarlet fever, 78; in sun- 
stroke, 396; in tetanus, 232. 

Hyperthyrea. 837. 

Hyperthyroidism. 836. 

Hypertrophic cirrhosis of liver, 574. 

Hypnotism in hysteria, 1121. 

Hypodermic syringe in diagnosis of pleural 
effusion, 675. 

Hypoglossal nerve, diseases of, 1066; paraly- 
sis of, 1066; spasm of, 1067. 

Hypophysis, enlargement of. 1143. 

Hypostatic congestion, of lungs, 635; in ty- 
phoid fever, 28. 

Hypotonia. 924. 

Hysteria, 1111; and disseminated sclerosis, 
960; contractures and spasms in, 1114; con- 
vulsive forms of, 1112; cries in, 1116; dis- 
orders of sensation in, 1115: forms of fever 
in, 1119: haemoptysis in, 1117; insanity in, 
1119: joint affections in. 111S; mental 
symptoms of, 1118; metabolism in. 1119; 
metallotherapy in, 1115: needle-swallowing 
in, 755: non-convulsive forms of. 1113: 
paralysis in, 1113: special senses in, 1116; 
stigmata in, 815, 1118; traumatic, 1132; 
visceral manifestations of, 1116. 

Hysterical angina pectoris, 763. 

Hystero-epilepsy, 1098. 1113. 

Hysterogenic points, 1116. 

Ice-cream, poisoning by, 393. 
Ice, typhoid bacillus in. 5. 
Ichthyosis lingualae, 446. 
Ichthyotoxismus. 393. 
Icterus (see Jaundice). 

Idiocy, in infantile hemiplegia, 1019; amau- 
rotic, 940. 
Idiopathic anaemia of Addison, 795. 
Idiopathic intermittent fever, 163. 



INDEX. 



1165 



Ileo-csecal region, in typhoid fever, 25; in ap- 
pendicitis, 525; in primary tuberculosis of 
bowel, 320. 

Ileus (see Strangulation of Bowel), 531. 

Imbecility in infantile hemiplegia, 1019. 

Imitation in chorea, 1081. 

Impetigo, contagious, and ulcerative stoma- 
titis, 442. 

Impotence, in diabetes, 427; in locomotor 
ataxia, 922. 

Impulsive tic, 1089. 

Incarceration of bowel, 531. 

Incoordination, of arms, 923; of legs, 923. 

Indians, American, chorea in, 1079; con- 
sumption in, 259; small-pox among, 56. 

Indicanuria, 863. 

Indigestion, 463. 

Infantile, convulsions, 1091; paralysis, 942; 

scurvy, 825. 
Infantilism, 243, 841. 
Infection, definition, 160. 
Infectious diseases, 1; of doubtful nature, 

342. 

Inflation of bowel in intussusception, 538. 

Influenza, 95; complications of, 97. 

Infusoria, parasitic, 351. 

Inhalation pneumonia (see Aspiration 
Pneumonia), 642. 

Inoculation, against small-pox, 56, 63; pro- 
tective, in cholera, 176; preventive, in 
hydrophobia, 229; preventive, in plague, 
192; preventive, in pneumonia, 112; pre- 
ventive, in yellow fever, 189; preventive, in 
typhoid fever, 41; tuberculosis transmitted 
by, 264. 

Insanity, post-febrile, 30; in small-pox, 64. 
Insanity, relation of drink to, 381; relations 

of chronic phthisis to, 312; relation of 

heart-disease to, 713. 
Insects, parasitic, 376. 
Insolation, 395. 
Insular sclerosis, 959. 

Intention tremor (see Volitional Tremor). 
Intermittent claudication, 763, 775. 
Intermittent fever, 209; forms of (see 
Fever). 

Intermittent hepatic fever, 566. 

Intermittent hydrarthrosis, 1118. 

Internal capsule, lesions of, 982, 983. 

Internal carotid artery, blocking of, 1011. 

Intestinal casts, 544; sand, 546. 

Intestinal coils, tumor formed by, 288. 

Intestinal obstruction, 531. 

Intestines, diseases of, 505; actinomycosis 
of, 236; dilatation of, 545. 

Intestines, haemorrhage from, in typhoid 
fever, 10, 23; in dysentery, 198, 200; in 
tuberculosis of bowel, 319; in intussuscep- 
tion of, 537; in ulceration of, 513. 

Intestines, infarction of, 546; intussuscep- 



tion of, 532, 537; invagination of, 532; mis- 
cellaneous affections of, 544; new growths 
in, 533. 

Intestines, obstruction of, 531, 599; acute, 
534; by enteroliths, 534; by foreign bodies, 
534; by gall-stones, 534, 568. 

Intestines, perforation of, in typhoid fever, 
10, 25. 

Intestines, primary tuberculosis of, 319; 
strangulation of, 531, 536; strictures and 
tumors of, 533; twists and knots in, 533; 
ulcers of, 512. 

Intoxication, definition of, 161. 

Intoxications, 380. 

Intussusception, 532, 537. 

Invagination, 532; post-mortem, 532. 

Inverse type of temperature, in acute tuber- 
culosis, 274; in typhoid fever, 16. 

Iodide eruptions, 254. 

Iridoplegia, 1047; accommodative, 1047; re- 
flex, 1047. 
Iritis, syphilitic, 241, 244. 
Itch insect, 376. 

Itching, of feet in gout, 415; of eyeballs in 
gout, 415; of skin in Bright's disease, 882; 
of skin in jaundice, 549; in diabetes, 425; 
in exophthalmic goitre, 839. 

Ixodes ricinus, 376. 

Jacksonian epilepsy, 917, 1098. 
Jail fever, 49. 

Jaundice, 548; black, 549; catarrhal, 555; 
choluria in, 549; from cirrhosis of liver, 
572, 575; epidemic form of, 344, 550; feb- 
rile, 344; from acute yellow atrophy, 551; 
from cancer of liver, 584; in diphtheria, 
150; from gall-stones, 564, 566; in influenza, 
97; in pneumonia, 125; and purpura, 814, 
549; in Weil's disease, 344; malignant, 551; 
of the new-born, 551; obstructive, 548; 
toxsemic, 550; xanthelasma in, 549; in yel- 
low fever, 185. 

Jaw clonus, 931. 

Jigger, 378. 

Joints (see Arthritis). 
Jumpers, 1089. 
" June cold," 612. 

Kahler's disease, albumosuria in, 857. 

Kakke, 221. 

Kala-azar, 203. 

Keloid of Addison, 1145. 

Keratitis, in small-pox. 65; interstitial, of in- 
herited syphilis, 244. 

Keratosis follicularis, 350. 

Keratosis mucosae oris, 446. 

Kidney, diseases of, 846; amyloid or larda- 
ceous disease of. 884; cancer of, 890; car- 
diac, 850; circulatory disturbance in, S49; 
cirrhosis of, 877; congenital cystic, 898; 



1166 



INDEX. 



congestion of, 849; contracted, 877; cya- 
notic induration of, 850; cystic disease of, 
898; echinococcus of, 374; floating, 846; 
fused, 846; gouty, 877; granular, 877; horse- 
shoe, 846; large white, 874; malformations 
of, 846; movable, 846; palpable, 846. 

Kidney, rhabdo-myoma of, 896; sarcoma of, 
896; scrofulous, 325, 887; small white kid- 
ney, 874; surgical kidney, 887; syphilis of, 
250; tuberculosis of, 324; tumors of, 896; 
unsymmetrical, 846. 

Klebs-Locffler bacillus, 140. 

Knee-jerk, loss of, in ataxia, 924; in diph- 
theria, 151. 

Koch treatment of tuberculosis, 335. 

Kopftetanus of Rose, 232. 

Koplik's sign, 87. 

Kreotoxismus, 391. 

Kubisagari, 1059. 

Labyrinthine disease, 1058. 

Lachrynial gland in mumps, 91; in Mikulicz's 

disease, 448. 
" Lacing " liver, 587. 
Lacunar tonsillitis, 451. 
La grippe, 95. 
Lamblia intestinalis, 351. 
Landry's paralysis, 946. 
Laparotomy in typhoid fever, 47. 
Larva? of flies, diseases caused by (myiasis), 

378. 

Laryngeal crises, 925. 

Laryngismus stridulus, 617; from pressure 
of enlarged thymus, 844. 

Laryngitis, acute, catarrhal, 615; chronic, 
616; oedematous, 617; spasmodic, 617; 
syphilitic, 620; tuberculous, 619. 

Larynx, diseases of, 615; adductor paralysis 
of, 1061; anaesthesia of, 1062; hyperes- 
thesia of, 1062; paralysis of abductors of, 
1061; spasm of the muscles of, 1062; uni- 
lateral abductor paralysis of, 1061. 

Latah, 1089. 

Lateral sclerosis, primary, 937 ; amyotrophic, 
928. 

Lateritious deposit, 860. 
Lathyrism, 394. 

Lead, colic, 388; in the urine, 387. 

Lead-palsy, 388; localized forms of, 388. 

Lead-poisoning, 386; acute, 387; arterio- 
sclerosis in, 389; cerebral symptoms in, 
389; chronic, 387; convulsions from, 389; 
gouty deposits in, 389; treatment of, 389. 

Lead-workers, prevalence of gout in, 408. 

Leichen-tubercle, 264. 

Leontiasis ossea, 1145. 

Lepra alba, 341; mutilans, 341. 

Leprosy, 338; anaesthetic, 342; bacillus leprae 
in, 340; contagiousness of, 340; macular 
form of, 341; tubercular, 341. 



Leptomeningitis, acute cerebro-spinal, 954; 

chronic, 957; infantum, 957. 
Leptothrix in mouth, 236. 
Leptus autumnalis, 376. 
Leucin, 552. 

Leucocytes, relation to uric acid, 409. 

Leucocytosis, in anaemia, 791, 799; chlorosis, 
794; cerebro-spinal meningitis, 104; diph- 
theria, 147; empyema, 672; erysipelas, 159; 
HodgMn's disease, 812; leukaemia, 806; 
malaria, 217; measles, 88; pyaemia, 165; 
pneumonia, 120; pleurisy, 670; rheumatic 
fever, 170; scarlet fever, 79; stomach can- 
cer, 489; in trichinosis, 357; in tuberculosis 
(acute), 275; in tuberculosis (chronic pul- 
monary), 311; typhoid fever, 19, 37; in 
whooping-cough, 94. 

Leucoderma, 839, 1146. 

Leucomata, 241. 

Leukaemia, 802; acute, 808; lymphatic, 808; 
blood in, 806; congenital, 803; definition of, 
802; heredity in, 802; in animals, 803; in 
pregnancy, 802; morbid anatomy of, 803; 
myelogenous, 802; prognosis in, 809; 
pseudo-, 809; spleno-medullary, 805. 

Leukoplakia buccalis, 446. 

Leydcn's crystals, 631, 633. 

Lienteric diarrhoea, 507. 

Life assurance and albuminuria, 858; and 

syphilis, 255. 
Lightning pains in ataxia, 922. 
Lineae atrophicae, 18. 
Lingual corns, 446. 
Lipaciduria, 864. 
Lipaemia, 421, 426. 
Lipothymia, 599. 

Lips, tuberculosis of, 317; chancre of, 238. 

Lipuria, 425, 864. 

Lithaemia, 859, 860. 

Lithic-acid diathesis, 859. 

Lithuria, 859. 

Little's disease, 938. 

Liver, abscess of, 577; actinomycosis of, 236; 
acute yellow atrophy of, 551; amyloid, 586; 
anaemia of, 553; angioma of, 584; cardiac, 
554; anomalies in form and position of, 587. 

Liver, cirrhosis of, 569; alcoholic, 570; 
ascites in, 572; atrophic, 571; capsular 
form, 575; in diabetes, 421; fatty, 571; 
haemorrhage from stomach in, 572; hyper- 
trophic, 574; syphilitic, 575; in tubercu- 
losis, 320; in children, 570; jaundice in, 572; ' 
toxic symptoms in, 573; with cancer, 583. 

Liver, cysts of, 584; fatty, 585; gummata of, 
248; hepato-phlebotomy in congestion of, 
554; hydatids of, 372; hyperaemia of, 553; 
infarction of, 554; melano-sarcoma of, 583; 
new growths in, 582; nutmeg, 553; passive 
congestion of, 553; periodical enlargement 
of, 553; primary cancer of, 582; psorosper- 



t 



IXDEX. 



iniasis of, 349; pulsation of, 554; sarcoma 
of, 583; secondary cancer of, 583; syphilis 
of, 248; tuberculosis of, 320; in typhoid 
fever, 11, 26. 
Liver, diseases of, 548. 

Liver dulness, obliteration of, in perforative 

peritonitis, 26, 598. 
Liver, movable, 542, 587. 
Living skeletons, 930. 
Lobar pneumonia, 108. 
Lobstein's cancer, 897. 
Localization, cerebral, 907; spinal, 905. 
Localized peritonitis, 522, 600. 
Lock-jaw, 230. 
Lock-spasm, 1108. 

Locomotive ataxia, 920; bladder symptoms 
in, 922; gastric crises in, 924; hemiplegia 
in, 925; nasal crises in, 925; paresis in, 925; 
rectal crises in, 924; relation of syphilis to, 
920; reputed cures of, 927. 

Long thoracic nerve, affections of, 1070. 

Loose shoulders, 934. 

Lucilia macellaria, 378. 

Ludwig's angina, 450. 

Lues venerea (syphilis), 238. 

Lumbago, 406. 

Lumbar plexus, lesions of, 1072. 

Lumbar puncture of Quincke, 107, 956, 1030. 

Lung, abscess of, 662; embolic, 662. 

Lung, actinomycosis of, 236; albinism of, 
656; brown induration of, 635; cancer of, 
acute, 664; carnification of, 643; cirrhosis 
of, 649. 

Lung, diseases of, 634; stones, 296. 
Lung fever, 108. 

Lungs, congestion of. 634; hypostatic, 635. 
Lungs, echinococcus of, 373. 
Lungs, gangrene of, 660; abscess of brain in, 
661. 

Lungs, new growths in, 663; in cobalt- 
miners, 664. 

Lungs, hsemorrhagic infarction of, 639; 
oedema of, 636; splenization of, 635, 643; 
syphilis of, 247; tuberculosis of, 289. 

Lupinosis, 394. 

Lymphadenitis, general tuberculous, 282; 
local tuberculous, 282; simple, 684; suppu- 
rative, 684. 

Lymphadenoma, general, 809. 

Lymphatic state, 826. 

Lymphatism, 826. 

Lymph-scrotum, 362. 

Lymph, vaccine, 72. 

Lymph vessels, dilatation of, 362. 

Lyssa, 227. 

Lyssophobia, 230. 

Maculae ceruleae, 18. 
Macular syphilides, 240. 
Maidismus, 395. 



1167 

Main en griffe, 930, 953. 

Maize, poisoning by (pellagra), 395. 

Malarial cachexia, 208, 216. 

Malarial fever, 203; accidental and late 
lesions of, 209; aestivo-autumnal, 213; algid 
form of, 215; comatose form of, 215; con- 
tinued and remittent form of, 213; descrip- 
tion of the paroxysm in, 209; geographical 
distribution of, 203; hsemorrhagic form of, 
216; intermittent, 209; pernicious, 208, 215; 
pneumonia in, 209; quartan, 213; quotidian, 
213; season in, 203; specific germ of, 204; 
tertian, 212. 

Malarial haemoglobinuria, 216. 

Malarial nephritis, 209. 

Malignant jaundice, 551. 

Malignant purpuric fever, 101. 

Malignant pustule, 225. 

Mallein, 234. 

Malta fever, 219. 

Mammary glands, hypertrophy in tubercu- 
losis, 312; tuberculosis of, 327. 
Mania a potu, 382. 
Mania, Bell's, 1075. 

Marriage, question of, in haemophilia, 821; 
in syphilis, 254; in tabes dorsalis, 927; in 
tuberculosis, 329. 

Marrow of bones, in small-pox, 58; in leukae- 
mia, 803; in pernicious anaemia, 797. 

Masque dcs fannies enceintes, 831. 

Massai disease, 363. 

Mastication, spasm of the muscles of, 1051. 

Mastitis in typhoid fever, 31. 

McB urncy's tender point, 525. 

Measles, 85; buccal spots in, 87; complica- 
tions and sequelae of, 87; contagiousness 
of, 85; desquamation in, 87; eruption in, 
86; German, 89; period of incubation in, 86. 

Measly meat, examination of, 367. 

Meat, poisoning by, 391; tuberculous infec- 
tion by, 267; inspection of, for trichinae, 
355. 

Meckel's diverticulum, 532. 

Median nerve, affections of, 1071. 

Mediastinal friction, 687. 

Mediastino-pericarditis, indurative. 687. 

Mediastinum, affections of, 684; abscess of, 
686; tumors of, 685; cancer of, 685; emphy- 
sema of, 687; pleural effusion in, 686; 
sarcoma of, 685. 

Mediterranean fever, 219. 

Medulla oblongata, lesions of, 9S4; tumors 
of, 1023. 

Megalo-cephaly, 1145. 

Megalocytes, 798. 

Megastrie, 17.">. 

Melaena, in duodenal ulcer, l .si : in typhoid 
fever, 23; in tuberculosis of bowels, 319; 
neonatorum, 818. 

Melano-sarcoina of liver, 583. 



1168 



INDEX. 



Melanuria, 863. 

Melasma suprarenale, 831. 

Meniere's disease, 1058. 

Meningeal haemorrhage, 999; in birth palsies, 
938. 

Meninges, affection of, 951. 

Meningitis, acute cerebro-spinal, 954; epi- 
demic cerebro-spinal, 100; in erysipelas, 
158, 159; in gout, 415; in typhoid fever, 12, 
14, 28; simple, of infants, 957; pseudo, 955; 
serosa, 1028; syphilitic, 245; tuberculous, 
276. 

Meningococcus, 102. 

Meningo-encephalitis, chronic diffuse, 960; 

tuberculous, 277. 
Mercurial, tremor, 1079; stomatitis, 444. 
Merycismus, 499. 

Mesenteric artery, aneurism of, 546; embo- 
lism of, 546; thrombosis of, 546. 

Mesenteric glands, tuberculosis of, 283; 
tuberculous tumors of, 288; in typhoid 
fever, 10. 

Mesenteric veins, diseases of, 547. 

Mesentery, chylous cysts of, 547; affections 
of, 546. 

Metallic echo. 683; tinkling, 309, 683. 
Metallotherapy, 1115. 
Metastatic abscesses, 164. 
Metasyphilitic affections, 242. 
Metatarsalgia, 1106. 

Meteorism in typhoid fever, 24; treatment 
of, 46. 

Micrococci, in dengue, 99; in Malta fever, 

219; in vaccine virus, 70. 
Micrococcus lanceolatus, 108, 110, 644, 702. 
Micrococcus rnelitensis, 219. 
Microcytes, 798. 
Micromegaly, 1145. 
Micromelia, 841. 

Middle cerebral artery, embolism and throm- 
bosis of, 1011. 

Migraine, 1102; treatment of, 1103. 

Miliary abscesses in typhoid fever, 11. 

Miliary aneurism, 998. 

Miliary fever, 346; epidemics of, 347. 

Miliary tubercle, 270; tuberculosis, acute, 
273; tuberculosis, chronic, 295. 

Milk and scarlet fever, 76; and typhoid 
fever, 6; products, poisoning by, 393; sick- 
ness, 344; tuberculous infection by, 267. 

Mind-blindness, 992. 

Mind-deafness, 992. 

Miner's, anaemia or cachexia, 360; lung, 652; 
nystagmus, 1047; cancer of lung, 664. 

Mitchell, Weir, treatment in hysteria, 1121. 

Mitral incompetency, 717. 

Mitral stenosis, 721; chorea and, 721; paraly- 
sis of recurrent laryngeal in, 725; presys- 
tolic murmur in, 723; rheumatism and, 721. 

Moist sounds, 308. 



Molluscum contagiosum, parasites in, 350. 
Monophobia, 1124. 

Monoplegia, cerebral, 916, 980; facial, 1052; 
in hysteria, 1114; in traumatic neuroses, 
1134. 

Montaigne on renal colic, 893. 

Montreal General Hospital, autopsies in 
diphtheria, 144; in typhoid fever, 8; sta- 
tistics, of apex lesions in 1,000 autopsies, 
332; of haemorrhagic small-pox, 62; of 
pneumonia, 131; of rheumatic ferer, 167; 
of typhoid fever, 3. 

Montreal small-pox epidemic 18S5-'S6, 65, 73. 

Morbilli haemorrhagici, 87. 

Morbus, caeruleus, 768. 

Morbus, coxae senilis, 401, 403; errorum, 377; 

maculosus, 814. 
Morbus maculosus neonatorum, 818. 
Morphia habit, 3S4; treatment of, 385. 
Morphinism, 384. 
Morphinomania, 384. 
Morphoea, 1145. 

Mortality, in cerebro-spinal meningitis, 107; 
in pneumonia, 131; in typhoid fever, 39; in 
whooping-cough, 94: in yellow fever, 188. 

Morton's painful foot, 1106. 

Morvan's disease, 975. 

Mosquitoes, relation of, to filaria disease, 
361. 

Motor tract, diseases of, 928. 

Mountain, anaemia, 346, 360; fever, 346; 

sickness, 346. 
Mouth-breathing, 454. 

Mouth, diseases of, 441; dry, 447; putrid 
sore, 442. 

Movable kidney, 542, 846; dilatation of 

stomach in, 848. 
Movable liver, 542, 587. 
Mucous colitis, 544. 
Mucous patches, 241. 
Muguet, 443. 
Multiple gangrene, 1138. 
Multiple sclerosis, 959. 
Mumps, 90, 447. 

Munich, reduction of typhoid mortality in, 
40. 

Murmur, in aneurism, 780; brain, 437; cardio- 
respiratory, 308; in chlorosis, 794; in con- 
genital heart-disease, 769; Flint's, 713; in 
endocarditis, 703; in lung cavity, 309; in 
subclavian artery in phthisis, 308; in val- 
vular disease, 713. 716, 720, 723, 726, 727. 

Musca domestica, 378; M. vomitoria, 378. 

Muscle callus in sterno-mastoid in infants, 
1064. 

Muscle, diseases of, 1148; degeneration of, in 
typhoid fever, 12, 32. 

Muscular atrophy, forms of, 934; heredity 
in. 933: atrophic and hypertrophic varie- 
ties, 935; infantile form, 935; juvenile 



INDEX. 



1169 



type, .935; progressive neural form, 933; 

peroneal type, 933. 
Muscular atrophy, progressive central, 928, 

941; hereditary influence in, 929. 
Muscular contractures in hysteria, 1114. 
Muscular dystrophies, 933. 
Muscular exertion, coma after, 869. 
Muscular exertion in heart-disease, 710, 745. 
Muscular rheumatism, 406. 
Muscle-sense, 992. 
Musculo-spiral paralysis, 1070. 
Musical faculty, loss of, in aphasia, 991. 
Musical murmurs, 716, 769. 
Mussel poisoning, 393. 
Myalgia, 406. 
Myasthenia gravis, 947. 
Myasthenic reaction, 947. 
Mycosis intestinalis, 226; pulmonum, 226. 
Mycotic gastritis, 466. 
Myelsemia, 802. 

Myelitis, acute, 976; acute diffuse, 977; acute 
transverse, 978; compression, 970; in 
measles, 88; reflexes in, 978; transverse, of 
cervical region, 979; syphilitic, 245, 246. 

Myelocytes, 806. 

Myelogenous leukaemia, 802. 

Myiasis, 378; of nostrils and of ears, 378; of 
vagina, 378; cutaneous, 378; interna, 378. 

Myocarditis, 748; acute interstitial, 748; 
fibrous, 747; in rheumatism, 171; segment- 
ing, 21, 748; in typhoid fever, 12, 21. 

Myocardium, diseases of, 746; lesions of, due 
to disease of coronary arteries, 746. 

Myoclonia, 1150. 

Myoclonies, 1150. 

Myoidema, 308. 

Myopathies, the primary, 933. 

Myositis, 1148; ossificans progressiva, 1149. 

Myotonia, 1149; congenita, 1149. 

Myotonic reaction of Erb, 1149. 

Myriachit, 1089. 

Mytilotoxin, 393. 

Mytilotoxismus, 393. 

Myxedema, 840; acute, 842; congenital form, 
840; operative, 842. 

Nails, in' typhoid fever, 18; in phthisis, 313. 
Nasal diphtheria, 147. 
Naso-pharyngeal obstruction, 454. 
Neapolitan fever, 219. 
Neck, cellulitis of, 450. 

Necrosis, acute, of bone, 173; in typhoid 

fever, 32. 
Necrosis in tubercle, 271. 
Needle-swallowing in hysteria, 755. 
Nematodes, diseases caused by, 352. 
Nephralgia, 1106. 

Nephritis, 869; acute, 809; after diphtheria, 
150; chronic, 874; chronic hemorrhagic, 
875. 

73 



Nephritis, chronic interstitial, 877; haemor- 
rhages in, 882; increased tension in, 880; 
malarial, 209; relation of heart hyper- 
trophy to, 879; syphilitic, 250; urine in, 
880; vomiting in, 881. 

Nephritis, chronic parenchymatous, 875; 
consecutive, 886; in erysipelas, 159; in ma- 
laria, 209; in scarlet fever, 80; in typhoid 
fever, 31. 

Nephritis, lymphomatous, 31; suppurative, 
887. 

Nephrolithiasis, 891. 

Nephro-phthisis (see Kidney, Tuberculosis 
of). 

Nephroptosis, 542, 846. 

Nephrorrhaphy, 849. 

Nephrotomy, 889. 

Nephro-typhus, 31. 

Nerve-fibres, inflammation of, 1031. 

Nerve-root symptoms, 970. 

" Nerve-storms," 1103. 

Nerves, diseases of peripheral, 1031; dis- 
eases of cerebral, 1038; diseases of spinal, 
1067. 

Nerves, lesions of anterior crural, 1072; cir- 
cumflex, 1070; external popliteal, 1072; 
gluteal, 1072; internal popliteal, 1072; long 
thoracic, 1070; median, 1071; musculo- 
spiral, 1070; obturator, 1072; sciatic, 1072; 
small sciatic, 1072; ulnar, 1071. 

Nervous diarrhoea, 506, 1117. 

Nervous dyspepsia, 497. 

Nervous system, diseases of, 901; diffuse, 
951. 

Nettle rash (see Urticaria). 

Neuralgia, 1104; causes of, 1104; cervico- 
brachial, 1105; cervico-occipital, 1067, 1105; 
influence of malaria in, 1104; intercostal, 
1105; lumbar, 1100; of nerves of feet, 1106; 
phrenic, 1105; plantar, 1106; red, 1139; re- 
flex irritation in, 1104; treatment of, 1107; 
trifacial, 1105: visceral, 1106. 

Neurasthenia, 1122; sexual, 1126; traumatic, 
1132. 

Neuritis, 1031; arsenical, 1035; from beer, 
1035; fascians, 1032; interstitial, 1031; of 
infants, progressive interstitial hyper- 
tropiiic, 951; lipomatous, 1031; localized, 
1031, 1032; parenchymatous, 1031; multi- 
ple, 1031, 1033; alcoholic, 1034; endemic, 
220, 1035; in diphtheria, 151; in chronic 
phthisis, 312; in the infectious diseases. 
1034; in typhoid fever, 29; recurring, 1033; 
saturnine, 1035; traumatic, 1032; optic, 
1040; from zinc. 1035. 

Neuroglioma, 1020. 

Neuroma, p lex i form, 1037. 

Neuromata, 1037. 

Neuroses, occupation, 1107; traumatic, 1132. 
Neutrophiles, 806. 



1170 



INDEX. 



New-born, hemorrhagic diseases of, 818. 
New growths in the bowel, 533. 
Night-blindness, 1040; in scurvy, 824. 
Night-sweats in phthisis, 306; treatment of, 
337. 

Night-terrors, 455. 

Nipple, Paget' s disease of, 350. 

Nits, 377. 

Nodding spasm, 1066. 
Nodes, Heberdcn's, 401. 

Nodes, symmetrical, in congenital syphilis, 
244. 

Nodules, rheumatic, 172. 

Noma, 444; in scarlet fever, 82; in typhoid 

fever, 33, 35. 
Normoblasts, 794, 799. 

Nose, bleeding from (see Epistaxis), 614. 
Nose, diseases of, 610. 
Nummular sputa in phthisis, 300. 
Nurse's contracture of Trousseau, 1110. 
Nutmeg liver, 553. 
Nyctalopia, 1040; in scurvy, 824. 
Nystagmus, 1047; in Friedreich's ataxia, 950; 
in insular sclerosis, 959; of miners, 1047. 

Obesity, 439. 
Obsession, 1089. 

Obstruction of bowels, 531; acute, 534; 
chronic, 535. 

Obturator nerve, affections of, 1072. 

Occipital lobes, tumors of, 1022. 

Occipitocervical neuralgia, 1087, 1105. 

Occupation neuroses, 1107. 

Ocular palsies, treatment of, 1050. 

Oculo-motor paralysis, recurring, 1046. 

Odor, in small-pox, 68; in typhoid fever, 18. 

(Edema, angio-neurotic, 1140; febrile pur- 
puric, 815; hereditary, 1141; of lungs, 636; 
of brain, 997; in uremia, 866, 997. 

(Edematous laryngitis, 617. 

Oertel's method in obesity, 440, 752. 

(Esophageal bruit, 461. 

(Esophago-pleuro-cutaneous fistula, 462. 

(Esophagismus, 459. 

Oesophagitis, acute, 458; chronic, 459. 

(Esophago-malacia, 462. 

(Esophagus, diseases of, 458; cancer of, 461; 
dilatations of, 462; diverticula of, 432; 
haemorrhage from, in cirrhosis of liver, 572; 
paralysis of, 459; post-mortem digestion 
of, 462; rupture of, 462; spasm of, 459; 
stricture of, 460; syphilis of, 249; tubercu- 
losis of, 318; ulceration of, 459; varices of 
veins., in cirrhosis of liver, 572. 

Oidium albicans, 443. 

Olfactory nerves and tracts, diseases of, 
1038. 

Omentum, tuberculous tumor of, 287 ; tumor 

of, in cancer of the peritonaeum, 605. 
Omodynia, 407. 



Onomatomania, 1089. 

Onychia, in arthritis deformans, 402; in 

locomotor ataxia, 925; syphilitic, 241, 243. 
Operation per se, effects of, in epilepsy, 1101. 
Operation, tuberculosis after, 270. 
Ophthalmia, gonorrhoeal, with arthritis, 173. 
Ophthalmoplegia, 942, 1049; externa, 1049; 

interna, 1049. 
Opisthotonos, cervical, in infants, 957; in 

tetanus, 232. 
Opium, poisoning, diagnosis from uraemia, 

868; habit, 384; smoking, effects of, 384. 
Optic nerve atrophy, 1041; hereditary, 1041; 

primary, 1041; secondary, 1041; in tabes, 

922. 

Optic nerve and tract, diseases of, 1039. 

Optic neuritis, 1040; in abscess of brain, 
1026; in brain-tumor, 1021; in tuberculous 
meningitis, 278. 

Orchitis, in malaria, 216; in mumps, 91; in- 
terstitial, in syphilis, 251; in typhoid fever, 
31; in variola, 58; parotidea, 91; tubercu- 
lous, 326; value of, in diagnosis, 326. 

Orthotonos, in tetanus, 232. 

Osteitis deformans, 1144. 

Osteo-arthropathy, hypertrophic pulmonary, 
1144. 

Osteo-myelitis simulating acute rheumatism, 
173. 

Otitis-media, in typhoid fever, 30; in scarlet 
fever, 81; in meningitis, 106; meningitic 
symptoms in, 955. 

Ovaries, tuberculosis of, 326. 

Over-exertion, heart affections due to, 745. 

Oxalate-of-lime calculus, 892. 

Oxaluria, 861. 

Oxygen, inhalations of, in diabetic coma, 

431; in pneumonia, 137. 
Oxyuris vermicularis, 353. 
Oysters, poisoning by, 393; and typhoid 

fever, 6. 
Ozaena, 612. 

Pachymeningitis, 951. 

Pachymeningitis cervicalis hypertrophica, 
953. 

Pachymeningitis haemorrhagica, of cerebral 

dura, 952; of spinal dura, 953. 
Palate, paralysis of, in diphtheria, 150; in 

facial paralysis, 1053; perforation of, in 

scarlet fever, 82. 
Palate, tuberculosis of, 318. 
Palpable kidney, 846. 
Palpitation of heart, 755. 
Palsies, cerebral, of children, 938, 1017. 
Palsy, lead, 388. 

Paludism (see Malarial Fever), 203. 
Pancreas, cancer of, 594; in diabetes, 421; 

cysts of, 592; haemorrhage into, 588; 

tumors of, 594. 



INDEX. 



1171 



Pancreas, diseases of, 588. 
Pancreatic abscess, 590; diabetes, 422; cal- 
culi, 595. 

Pancreatitis, acute haemorrhagic, 589; 
chronic, 592; fat necrosis in, 591; gangre- 
nous, 590; suppurative, 590. 

Pantophobia, 1124. 

Papillitis, 1040. 

Paraesthesia (numbness and tingling), in 
neuritis, 1032; in locomotor ataxia, 924; in 
tumor of brain, 1022; in primary combined 
sclerosis, 949. 

Parageusis, 1060. 

Paralysis, acute ascending, 946; acute spinal, 
of adults, 946; acute, of infants, 942; 
agitans, 1076; alcoholic, 1034; anaesthesia, 
1035; asthenic bulbar, 947; atrophic spinal, 
942; Bell's, 1051; bulbar, acute, 933; 
chronic, 933; of bladder, in myelitis, 977; 
of brachial plexus, 1069; in chorea, 1083; 
of circumflex nerve, 1070; crossed or alter- 
nate, 984, 1004; " crutch," 1070; Cruveil- 
hier's, 929; diver's, 969; of diaphragm, 
1068; after diphtheria, 150; following epi- 
lepsy, 1097; of facial nerve, 1051; of fifth 
nerve, 1050; of fourth nerve, 1047; general, 
of the insane, 960; of hypoglossal nerve, 
1066; hysterical, 1113; infantile, 942; 
labioglossal-laryngeal, 932; Landry's, 946; 
of laryngeal abductors, 1061; of adductors, 
1061; in lateral sclerosis, 937; from lead, 
388; in locomotor ataxia, 925; of long 
thoracic nerve, 1070; in meningitis, 278, 
956; of median nerve, 1071; of musculo- 
spiral nerve, 1070; of oculo-motor nerves, 
1046; of olfactory nerve, 1038; periodical, 
1136; in progressive muscular atrophy, 930; 
radial, 1070; of rectum, in myelitis, 977; 
of recurrent laryngeal nerve, 1061; sec- 
ondary to visceral disease, 1032; of sixth 
nerve, 1048; of third nerve, 1046; of ulnar 
nerve, 1071; of vocal cords, 1061. 

Paramyoclonus multiplex, 1150. 

Paraphasia, 991. 

Paraplegia flasqne, 941. 

Paraplegia, from alcohol, 1034; ataxic, 948; 
from anaemia of spinal cord, 966; from 
compression of cord, 970; diabetic, 427; 
from haemorrhage into cord. 968; hered- 
itary form of, 940; hysterical, 941, 1114; 
in lathyrism, 394; from myelitis, 977; in 
pellagra, 395; spastic, 9:57; spastica cere- 
bralis, 938; syphilitic, 940; from tumor of 
the cord, 974; in tabes, 925. 

Parasites, diseases due to animal, 349. 

Parasitic gastritis, 466. 

Parasitic stomatitis, 443. 

Parasyphilitic affections, 242, 961. 

" Parchment crackling " in rickets, 435. 

Parenchymatous nephritis, 875. 



Parieto-occipital region, brain tumors in, 
1022. 

" Paris green," poisoning by, 390. 
Parkinson's disease, 1076. 
Parosmia, 1038. 
Parotid bubo, 447. 

Parotitis, epidemic, 90; deafness in. 91; de- 
lirium in, 91; chronic, 447; orchitis in, 91; 
specinc, 447. 

Parotitis, symptomatic, 447; after abdominal 
section, 447; in pneumonia, 125; in typhoid 
fever, 22; in typhus fevei-, 52. 

Paroxysmal hsemoglobinuria, 853. 

Parrot's ulcers, 443. 

Parry's disease, 836. 

Patellar-tendon reflex (see Kxee-jerk). 

Pathophobia, 1124. 

Pectoriloquy, 309. 

Pediculi, 376; relations of, to tache bleuatre, 

18, 377. 
Pediculosis, 376. 

Pediculus capitis, 376; P. corporis, 377. 
Peliomata, 18. 

Peliosis rheumatica, 815; in chorea, 1085. 
Pellagra, 395. 

Pelvis of kidney, affections of (see Pye- 
litis). 

Pemphigoid purpura, 815. 
Pemphigus neonatorum, 242. 
Pentastomes, 375. 

Peptic ulcer, 478; dyspepsia in, 481; haemor- 
rhage in, 481; pain in, 481; tenderness on 
pressure in, 482. 

Peptones in the urine, 857. 

Perforating ulcer of foot in tabes, 925; in 
diabetes, 426. 

Perforation of bowel, in dysentery, 200; in 
typhoid fever, 10, 25. 

Periarteritis, gummatous, 250; nodosa, 788. 

Pericardial friction, 690. 

Pericarditis, 688; acute plastic, 689: aphonia 
in, 692; chronic adhesive, 696; delirium in, 
692; dysphagia in, 692; epidemics of, 689; 
epilepsy in, 693; from extension of disease, 
689; from foreign body. 688: in chorea. 
1084; in foetus, 689; in gout, 415: in rheuma- 
tism, 171; haemorrhagic, (592; hyperpyrexia 
in, 690, 092; mental symptoms in. 692; pri- 
mary, 688; pulsus paradoxus in. 692: 
secondary, 688; tuberculous, 285; with 
effusion, 691; in typhoid fever, 12. 20. 

Pericardium, adherent. 696; Friedreich's sign 
in. 697. 

Pericardium, diseases of, 688; tuberculosis 

of. 285; air in, 698. 
Perichondritis, laryngeal, In typhoid (ever, 

11, 27: in tuberculosis, 619. 
Perihepatitis, 575, 603. 
Perinephric abscess, 900. 
Perinuclear basophilic granules, 410. 



1172 



INDEX. 



Periodical paralysis, 1136. 

Periosteal cachexia, 825. 

Peripheral neuritis, 1031. 

Peristaltic unrest, 498, 1117. 

Peritonaeum, diseases of, 596. 

Peritonaeum, fluid in, 605, 609; cancer of, 
604; new growths in, 604. 

Peritonaeum, tuberculosis of, 286. 

Peritonaeum, tumor formations in tubercu- 
losis of, 287. 

Peritonitis, acute general, 522, 526, 596; ap- 
pendicular, 526, 602; chronic, 602; chronic 
haemorrhagic, 604; diffuse adhesive, 603; 
hysterical, 599; idiopathic, 596; in infants, 
600; in typhoid fever, 25; leukaemic, 805; 
local adhesive, 602; localized, 522, 600; pel- 
vic, 602; perforative, 596; primary, 596; 
proliferative, 603; pyaemic, 596; rheumatic, 
596; secondary, 596; septic, 596; sub- 
phrenic, 600; tuberculous, 286, C04. 

Peritonitis, tuberculous, effects of operation 
on, 609. 

Perityphlitis, 519. 

" Perles " of Laennec, 630. 

Pernicious anaemia, 795. 

Pernicious malaria, 208, 215. 

Peroneal type of muscular atrophy, 933. 

Pertussis (see Whooping-cough), 92. 

Pesta magna, 56. 

Pestis minor, 191. 

Petechiae in epilepsy, 1097; in relapsing 
fever, 54; in scurvy, 823; in small-pox, 62; 
in typhoid fever, 17; in typhus fever, 51. 

Petechial fever, 101. 

Petit mal, 1094, 1097; in general paresis, 962. 

Peyer's patches in typhoid fever, 8; in 
measles, 86: in tuberculosis, 319. 

Phagocytosis in erysipelas, 15S; in tubercu- 
losis, 271. 

Pharyngitis, 448; acute, 448; chronic, 449; 
sicca, 449. 

Pharynx, acute infectious phlegmon of, 450; 
haemorrhage into, 448; hyperaemia of, 448; 
oedema of, 448; paralysis of, 10G0: spasm 
of, 1061; tuberculosis of, 318; ulceration 
of, 449. 

Pharynx, diseases of, 448. 

Philadelphia Hospital, relapsing fever at, in 
1844, 53; statistics of cerebro-spinal fever, 
104; of delirium tremens in, 383. 

Philadelphia Infirmary for Nervous Dis- 
eases, statistics of chorea, 1079; of epi- 
lepsy, 1094. 

Philadelphia, tuberculosis in city wards, 
266; yellow-fever epidemic in 1793, 182; 
typhus epidemic in 1883, 49. 

Phlebitis of portal vein, 577. 

Phlebo-sclerosis, 773. 

Phosphates, alkaline, 862; earthy, 862. 

Phosphatic calculi, 892. 



Phosphaturia, 862. 

Phosphorus poisoning, similarity of acute 

yellow atrophy to, 553. 
Phrenic nerve, affections of, 1068. 
Phthiriasis, 376. 
Phthirius pubis, 377. 

Phthisical frame, Hippocrates' description 
of, 268. . 

Phthisis, 289; chronic ulcerative, 294; acute 
pneumonic, 289; arterio-sclerosis in, 316; 
basic form of, 295; Bright's disease in, 312; 
of coal-miners, 269, 652; chronic arthritis 
in, 316; cough in, 300; endocarditis in, 298, 
310; diagnosis of, 313; distribution of 
lesions in, 294; erysipelas in, 315; fatal 
haemorrhage in, 317; fever in, 304; forms 
of cavities in, 296; gastric symptoms of, 
311; haemoptysis in, 302; modes of death 
in, 317; modes of onset in, 298; physical 
signs of, 306; pneumonia in, 315; relation of 
fistula in ano to, 320; sputum in, 300; sum- 
mary of lesions in, 295; typhoid fever in, 
315; vomiting in, 311. 

Phthisis, fibroid, 314, 649; florida, 292; 
renum, 324; syphilitic, 247; of stone-cut- 
ters, 269, 652; unity of, 272; ventriculi, 467. 

Physiological albuminuria, 855. 

Pia mater, diseases of, 954. 

Picric-acid test for albumin, 857. 

Pigeon-breast, in rickets, 436; in mouth- 
breathers, 455. 

Pigmentation of skin, from arsenic, 390; in 
Basedow's disease, 839; from phthiriasis, 
377; in Addison's disease, 830; in chronic 
pulmonary tuberculosis, 313; in melanosis, 
831; in peritoneal tuberculosis, 287; in 
scleroderma, 1146. 

Pigmentation of viscera in pellagra, 395. 

Pigs, tuberculosis in, 258. 

Pin-worms, 353. 

Pittiug in small-pox, 61; measures to pre- 
vent, 67. 

Pituitary body in acromegaly, 1143; in gigan- 
tism, 1143. 

Pityriasis versicolor, 313. 

Plague, 189; bubonic, 191; septicaemic, 191; 
pneumonic, 191. 

Plague spots, 191. 

Plaques jaunes, 1009. 

Plastic bronchitis, 633. 

Pleura, diseases of, 665. 

Pleura, echinococcus of, 373; tuberculosis of, 
284. 

Pleural effusion, Baccclli's sign in, 670, 672; 
compression of lung in, 667; haemorrhagic, 
673; in scarlet fever, 81; position of heart 
in, 668; pseudo-cavernous signs in, 670; 
purulent, 671; serous effusion, constituents 
of, 667; sudden death in, 671. 

Pleural membranes, calcification of, 679. 



INDEX. 



1173 



Pleurisy, acute, 665; diaphragmatic, 674; en- 
cysted, 674; fibrinous, 665; interlobar, 674; 
in typhoid fever, 28; pain in side in, 668; 
plastic, 665; pleural friction in, 670; pulsat- 
ing, 672; purulent, 671; sero-fibrinous, 666; 
tuberculous, 284, 666, 673. 

Pleurisy, chronic, 678; dry, 679; primitive 
dry, 679; vaso-motor phenomena in, 680; 
with effusion, 678. 

Pleurodynia, 407. 

Pleuro-peritoneal tuberculosis, 284. 
Pleurothotonos in tetanus, 232. 
Plexiform neuroma, 1037. 
Plica polonica, 377. 

Plumbism, 386; and gout, 408; as a cause of 
renal cirrhosis, 877; paralysis in, 388. 

Plymouth, epidemic of typhoid fever at, 5. 

Pneumatosis, 499. 

Pneumaturia, 424, 864. 

Pneumococcus, 110. 

Pneumogastric aurae, 1096. 

Pneumogastric nerve, affections of, 1060; 
cardiac branches of, 1062; gastric and 
oesophageal branches of, 1063; laryngeal 
branches of, 1061; pharyngeal branches of, 
1060; pulmonary branches of, 1063. 

Pneumonia, acute croupous, 108; abscess in, 
130; acute delirium in, 123; anaesthesia, 
129; antipneumonic serum in, 135; bleeding 
in, 135; clinical varieties of, 126; colitis, 
croupous, in, 115; complications of, 123; 
crisis in, 117; delayed resolution in, 129; 
diagnosis from acute pneumonic phthisis, 
291; diplococcus pneumoniae, 110; endocar- 
ditis in, 115; engorgement of lung in, 113; 
epidemics of, 112; fever of, 116; gangrene 
in, 130; gray hepatization in, 113; herpes 
in, 122; immunity from, 112; in diabetes, 
127; in infants, 126; in influenza, 128; in 
old age, 126; meningitis in, 115; mortality 
of, 131; pericarditis in, 115; pseudo-crisis 
in, 117; purulent infiltration in, 113; re- 
currence of, 125; red hepatization in, 113; 
relapse in, 125; resolution of, 113; scrum 
therapy in, 112; toxaemia in, 132; trauma 
in, 109. 

Pneumonia, acute syphilitic, 248; apex pneu- 
monia, 126; aspiration or deglutition, 642; 
asthenic, 127; central, 126; " cerebral," 
122; chronic interstitial, 649; chronic 
pleuroffonous. 680; contusion, 10!); double, 
126; ether, 129; epidemic, 127; fibrinous, 
108; hypostatic, 635; in malaria, 209; inter- 
stitial, of (ho root, in syphilis, 247; in ty- 
phoid fever. 27; larval, 127: lobar, 108; 
massive, 126; migratory, 126; pleuroge- 
nous interstitial, 649; post-operation, 128; 
secondary, 127; toxic, 127; typhoid pneu- 
monia, 127; white, of the foetus, 247. 

Pneumonitis, 108. 



Pneumonokoniosis, 652. 
Pneumo-pericardium, 698. 
Pneumo-peritonaeum, 598. 
Pneumorrhagia, 637. 

Pneumothorax, 681; after tracheotomy, 687; 
chronic, 683; Hippocratic succussion in, 
683; in phthisis, 297; from muscular effort, 
681. 

Pneumo-typhus, 11, 27. 
Podagra, 407. 
Pododynia, 1106. 
Poikilocytosis, 794, 799. 

Poisoning, by arsenic, 390; by food, 391; by 
lead, 386; by meat, 391; by sewer-gas, 343. 
" Poker-back," 403. 

Polio-myelitis, acute and subacute, in adults, 
946. 

Polio-myelitis anterior, acute, 942; epidemics 

of, 942; etiology of, 942. 
Polio-myelitis anterior chronica, 928, 941. 
Polyadenomata, 494. 
Polyaemia, 803. 

Polyneuritis, acute febrile, 1033; recurrens, 
1033. 

Polyorrhomenitis, 284, 604. 

Polyphagia, 423. 

Polyserositis, 284, 604. 

Polyuria (see Diabetes Insipidus), 432. 

Polyuria, in abdominal tumors, 432; in 

hysteria, 432, 1112. 
Pons, lesions of, 984; tumors of, 1023. 
Popliteal nerve, external, 1072; internal, 

1072. 

Porencephalus, 1017. 

Portal vein, diseases of, 554; thrombosis of, 

554; suppuration in, 578. 
Post-epileptic symptoms, 1097. 
Post-hemiplegic chorea, 1019; epilepsy, 1019, 

1098; movements, 1019. 
Post-mortem movements in cholera bodies, 

178. 

Post-pharyngoal abscess, 450. 
Post-typhoid, anaemia, 19; variations of tem- 
perature, 16. 
Pott's disease, 970. 

Pregnancy, and acute yellow atrophy, 551; 

and chorea. 1080; and heart-disease, 729; 

and phthisis. 329; and typhoid fever, 35. 
Presystolic murmur, 723. 
Priapism in leukaemia, 806. 
Prickly heat (see UbtiCAHIA). 
Procession caterpillar, effects of, 379. 
Professional spasms, 1107. 
Proglottis of taenia, 365. 
Progressive muscular atrophy, 928. 
Progressive pernicious ansemla, 795; blood 

in. 797. 

Prophylaxis, against cholera. ISO; against 
scurvy. 824: against tuberculosis, 330; 
against, taenia, ."!67; against trichina, 359; 



1174 



IXDEX. 



against typhoid fever, 40; against yellow 

fever, 188. 
Prosopalgia. 1105. 
Prostate, tuberculosis of, 326. 
Protozoa, diseases caused by, 349; parasitic. 

349. 

Prune-juice expectoration, 664. 
Prurigo, in Eodgkin's disease, 812. 
Pruritus in diabetes, 425: in uraemia, 867; in 

obstructive jaundice, 549: in gout, 415; in 

Graves' disease, 839. 
Pseudo-angina pectoris, 763, 1118. 
Pseudo-apoplectic seizures in fatty heart, 

751; with slow pulse, 760. 
Pseudo-biliary colic, 564. 
Pseudo-bulbar paralysis, 932. 
Pseudo-cavernous signs, 309, 670, 675. 
Pseudo-cyesis, 1114. 
Pseudo-diphtheria. 142. 
Pseudo-hydrophobia, 230. 
Pseudo-leukaemia, 809. 
Pseudo-lipoma, supraclavicular, 841. 
Pseudo-ptosis, 1046. 
Pseudo-sclerose en plaques, 960. 
Pseudo-tuberculosis hominis streptothrica, 

262. 
Psilosis, 511. 
Psoriasis, buccal, 446. 
Psorosperiniasis. 349. 

Ptosis, forms of. 1046; hysterical, 1046; in 
ataxia, 922; pseudo-, 1046. 

Ptyalism, 444, 446. 

Puberty, barking cough of, 1117. 

Pulex, irritans, 377; penetrans, 378. 

Pulmonal-cerebral abscesses, 1025. 

Pulmonary (see LiTJKgs). 

Pulmonary apoplexy. 638. 

Pulmonary artery, sclerosis of, 773; perfora- 
tion of, 782. 

Pulmonary haemorrhage, 637. 

Pulmonary orifice, congenital lesions of, 767: 
tuberculosis in, 316, 767: valve lesions of, 

Pulmonary osteo-arthropathy, hypertrophic, 
1144. 

Pulsating pleurisy. 672. 

Pulsation, dynamic, of aorta, 782. 

Pulse, alternate, 757; anastomotic, 774: 
dicrotic, 13, 19: under influence of digi- 
talis, 732; intermittent, 757; irregular, 757: 
bigeminal, 757; recurrent, 774; trigeminal. 
757. 

Pulse, capillary (see Capillary); Corrigan, 

714; water-hammer, 714. 
Pulse, slow, in tuberculous meningitis. 279: 

in jaundice, 549 (see Brachycardia, 759). 
Pulsus paradoxus. 692, 697. 756. 
Pupil, Argyll Robertson. 962. 1047. 
Pupillary inaction, hemiopic. 1044. 
Pupils, unequal, 1047; in general paresis, 962. 



Purpura, S14; arthritic, 815; cachetic, 814; 
fulminans, 817; Henoch's, 816; infectious, 
814; mechanical, S15: neurotic, 815; pelio- 
sis rheumatica in, 815; haemorrhagica, 816; 
pemphigoid, 815; simplex, 815: sympto- 
matic, 814; toxic, 814: urticans, 815; vario- 
losa, 62. 

Purpuric oedema, febrile, 815. 

Pustule, malignant, 225. 

Putrid sore mouth, 442. 

Pyaemia, 163; arterial, 705; idiopathic, 163; 
post-typhoid, 32. 

Pyaemic abscess of liver, 579, 580. 

Pyelitis, 886; intermittent fever in, 888; 
pyuria in, 887; in typhoid fever, 31. 

Pyelonephritis, 886. 

Pylephlebitis adhesiva, 554. 

Pylephlebitis, in dysentery, 200; in pyaemia, 
164; suppurative, 555, 578. 

Pylorus, hypertrophic stenosis of, 494; con- 
genital hypertrophy of, 494; insufficiency 
of, 500; spasm of, 499. 

Pyonephrosis, 886. 

Pyo-pneumothorax, 285, 681. 

Pyo-pneumothorax subphrenicus. 479, 601, 
683. 

Pyuria, 858; in typhoid fever, 31. 

Quarantine against yellow fever, 188; 

against cholera, 180. 
Quartan ague, 213. 
Quincke's lumbar puncture, 107, 956. 
Quinine rash, 77, 83. 

Quinsy (see Tonsillitis, Suppurative). 
Quotidian ague, 213. 

Rabies, 227. 
Rachitic bones, 434. 
Radial paralysis, 1070. 
Rag-picker's disease, 226. 
Railway brain, 1132. 
Railway spine, 1132. 
Raincy's tubes, 349. 
Rapid heart, 758. 

Rashes, from drugs, 83, 814; in glanders, 234; 
in measles, 86; in relapsing fever, 54; in 
rubella, 89; in scarlet fever, 77; in small- 
pox, 59. 60; in syphilis, 240; in typhoid 
fever. 17: in typhus fever, 51; in pyaemia, 
164; in vaccination, 71; in varicella. 74. 

Raspberry tongue in scarlet fever, 78. 

Ray-fungus (actinomyces), 235. 

Raynaud's disease, 1137; aphasia in, 1139; 
and scleroderma, 1146; epilepsy in, 1139; 
haemoglobinuria in, 1138. 

Reaction of degeneration, 914, 1036, 1054. 

Recrudescence of fever in typhoid fever, 16. 

Rectal crises in tabes, 924. 

Rectum, irritable, 1118; stricture of, 249; 
syphilis of, 249; tuberculosis of, 320. 



INDEX. 



1175 



Recurrent laryngeal nerve, paralysis of, 
1061. 

Recurrent pulse, 774. 

Recurring multiple neuritis, 1033. 

Red softening of brain, 1009. 

Reduplication of heart-sounds, 757. 

Redux crepitus, 120. 

Reflex epilepsy, 1095. 

Reflexes in ascending paralysis, 946; in cere- 
bral haemorrhage, 1005, 1006; in locomotor 
ataxia, 924; in polio-myelitis acuta, 944; in 
spastic paraplegia, 937; in hysterical para- 
plegia, 941, 1114; in progressive muscular 
atrophy, 931. 

Regurgitation, tricuspid, 725. 

Reichmann's disease, 500. 

Relapse in typhoid fever, 35. 

Relapsing fever, 53; spirillum of, 54. 

Remittent fever, 213. 

Renal calculus, 891. 

Renal, colic, 893; epistaxis, 852; sand, 892; 

syphilis, 250; sclerosis, 877. 
Rendu' s type of tremor, 1115. 
Ren mobilis, 846. 
Resolution in pneumonia, 129. 
Resonance, amphoric, 309, 682; tympanitic, 

300, 669, 682. 
Respiratory system, diseases of, 610. 
Rest treatment, 1121; in aneurism, 784. 
Retina, lesions of, 1039. 
Retinal hyperaesthesia, 1040. 
Retinitis, albuminuric, 1039; in anaemia, 

1039; in malaria, 1039; leukaemic, 1040; 

pigmentosa, 1039; syphilitic, 241, 1039. 
Retraction of head in meningitis, 278, 955; 

in otitis media, 955; in typhoid fever, 28. 
Retro-collic spasm, 1065. 
Retroperitoneal abscess, 522. 
Retroperitonaeum, haemorrhage into, 58. 
Retro-pharyngeal abscess, 450. 
Retropulsion in paralysis agitans, 1078. 
Revaccination, 71. 
Rhabditis niellyi, 361. 
Rhabdo-myoma of kidney, 896. 
Rhabdonema intestinale, 364. 
Rhachitis, 434. 
Rhagades, 243. 

Rheumatic fever, 166; cerebral complications 
of, 171; endocarditis in, 170; fibrous 
nodules in, 172; germ theory of, 108; 
heredity in, 167; hyperpyrexia in, 170; 
metabolic theory of, 168; nervous theory 
of, 168; pericarditis in, 171; purpura in, 
172; sudden death in, 172. 

Rheumatic gout (see Artiiiutis Defor- 
mans). 

Rheumatic nodules, 172. 
Rheumatism, chronic, 405. 
Rheumatism, muscular, 406. 
Rheumatism, subacute, 170. 



Rheumatoid arthritis (see Arthritis De- 
formans). 

Rhinitis, 611; atrophica, 611; fibrinosa, 147; 
hypertrophica, 611; syphilitic, 242. 

Ribs, resection of, in empyema, 678. 

Rice-water stools, 179. 

Rickets, 434; acute, 438, 825; foetal, 841. 

Riga's disease, 442. 

Rigidity, early, in hemiplegia, 1002. 

Rigidity, late, in hemiplegia, 1005. 

Rigors, in abscess of brain, 1026; in abscess 
of liver, 579; in ague, 209; in pneumonia, 
115; in pyaemia, 164; in pyelitis, 887; in 
tuberculosis, 299; in typhoid fever, 17. 

Risus sardonicus, 232. 

Rock-fever, 219. 

Romberg's symptom, 923. 

Root-nerve symptoms in compression para- 
plegia, 970. 

Rosary, rickety, 436. 

Roseola (see Rose Rash of Typhoid), 17; 

epidemic, 89. 
" Rose cold," 612. 
Rose rash in typhoid fever, 17. 
Rotation in epilepsy, 1096. 
Rotatory spasm in hysteria, 1115. 
Rotheln, 89. 

" Rough-on-rats," poisoning by, 390. 

Round-worms, 352. 

Rub (see Friction). 

Rubella, 89. 

Rubeola notha, 89. 

Rumination, 499. 

Running pulse in typhoid fever, 19. 
Russian fever, 95. 

Sable intestinal, 546. 

Saccharomyces albicans, 443. 

Sacral plexus, lesions of, 1072. 

St. Vitus' s dance, 1079. 

Salaam convulsions, 1091, 1115. 

Saline injections, intravenous, in diabetic 
coma, 431; subcutaneous, in cholera, 181. 

Saliva, arrest of, 447; supersecretion of, 44(5. 

Salivary glands, diseases of, 446; inflamma- 
tion of, 447. 

Salivation (see Ptyamsmi, 444. 446; in small- 
pox, 61; in bulbar paralysis, 932. 

Salpingitis, tuberculous, 326. 

Saltatory spasm. 1089. 

Sanatoria, treatment of tuberculosis in, 333. 
Sand-flea, 378. 
Saprsemla, 161. 
Saranac Sanitarium, 333. 
Sarclna, ventriculi, 475; in lung cavities, 302. 
Sarcocystls Miescheri, 349; S. hominis, 
340. 

Sarcoma, of brain, 1020; of kidney, 896; of 
liver, 5S3; of lung. *»«>:? : mediastinal, 685; 
melanotic, of liver, 583. 



1176 



INDEX. 



Sarcoptes scabiei, 376. 

Saturnine neuritis, 1035. 

Saturnism, 386. 

Sausage poisoning, 391. 

Seapulodynia, 407. 

Scarlatina miliaris, 78. 

Scarlatina sine eruptione, 79. 

Scarlatinal nephritis, 80. 

Scarlet fever, 75; anginose form, 80; atactic 
form, 79; complications and sequelae, 80; 
contagiousness of, 76; desquamation in, 
79: eruption in, 77; hemorrhagic form, 79; 
incubation of, 77; invasion in, 77; malig- 
nant, 79; puerperal, 76; surgical, 76. 

Schistosoma haematobium, 352. 

Schonlein's disease, 815. 

School-made chorea, 1081. 

Schott treatment in myocardial disease, 
752. 

Sciatica, 1073. 

Sciatic nerve, affections of, 1072. 

Scirrhous cancer of stomach, 487, 488. 

Sclerema in cholera infantum, 510. 

Sclerema neonatorum, 1145. 

Sclerodactylie, 1146. 

Scleroderma, 1145. 

Sclerose en plaques, 959. 

Scleroses of the brain, 957. 

Sclerosis, cerebro-spinal, 957; degenerative, 
957; developmental, 958; inflammatory, 
958; of scurvy, 823; syphilis as a cause of, 
242. 

Sclerosis, primary, lateral, 937; insular, 959; 

multiple, 959. 
Sclerosis, posterior spinal (see Locomotor 

Ataxia), 920; in chronic ergotism, 394. 
Sclerosis, primary combined, 949. 
Sclerosis in tubercles, 271. 
Sclerosis, renal, 877. 
Sclerosis, toxic combined, 951. 
Sclerostomum duodenale, 359; S. equinum, 

359. 

Sclerotic gastritis, 467. 
Scolices of echinococcus, 371. 
Scorbutus, 821. 
Scrivener's palsy, 1107. 

Scrofula, 280; alleged protective inoculation 

by, 281. 
Scrofulous pneumonia, 272. 
Scurvy, 821; infantile, 825; prophylaxis of, 

824; sclerosis, 823. 
Scybala, 539. 

Seasonal relations, of chorea, 1079; of ma- 
laria, 203; of pneumonia, 110; of rheuma- 
tism, 167. 

Secondary contracture in hemiplegia, 1005. 
Secondary deviation, 1048. 
Secondary fever of small-pox, 60. 
Self-limitation in tuberculosis, 328. 
Semilunar space of Traube, 669. 



Semilunar valves, aortic, incompetency of, 
709. 

Senile emphysema, 659. 

Sensation, painful, loss of, in syringomyelia, 
975. 

Sensation, retardation of, in ataxia, 924. 

Sensory system, diseases of, 920. 

Septicaemia, 160; cryptogenetic, 162; general, 
162; gonorrhceal, 255; progressive, 162; 
post-typhoid, 32. 

Septico-pyaemia, 163. 

Serratus palsy, 1070. 

Seven-day fever, 53. 

Sewer-gas and tonsillitis, 451. 

Sewer-gas poisoning, effects of, 343. 

Sex, influence of, in heart-disease, 729. 

Sexes, proportion of, affected with acute 
yellow atrophy, 551; in chlorosis, 792; in 
chorea, 1079; in exophthalmic goitre, 837: 
in general paresis, 960; in haemophilia, 819. 

Shaking palsy, 1076. 

Shell-fish, poisoning by, 393. 

Ship-fever, 49. 

Shock as a cause of traumatic neuroses, 
1132. 

Shock, death from, in acute obstruction, 
535. 

Sick headache, 1102. 
Sickness, sleeping, 361. 
Siderodromophobia, 1124. 
Siderophobia, 1124. 
Siderosis, 652, 654. 

Signal symptom (in cortical lesions), 980, 
1021. 

Singultus (see Hiccough). 

Sinus thrombosis, 1015; and anaemia, 1015: 
and chlorosis, 794; autochthonous, 1015; 
secondary, in ear-disease, 1015. 

Siriasis, 395. 

Sitotoxismus, 394. 

Sixth nerve, paralysis of, 1048. 

Skin, itching of, in uraemia, 867. 

Skoda' s resonance in pleural effusion, 669; 
in pneumonia, 119. 

Skull, of congenital syphilis, 243; of hydro- 
cephalus, 1029; of rickets, 436; percussion 
of, 1027. 

Sleeping sickness, 361. 

Slow heart, 759. 

Small-pox, 56; complications of, 64; con- 
fluent form, 61; contagiousness of, 56; 
discrete form, 60; eruption in, 60; haemor- 
rhagic, 62; inoculation in, 56; vaccination 
in, 56. 

Small sciatic nerve, affections of, 1072. 
Smell, affections of sense of (see Olfactory 

Nerve), 1038. 
Snake-virus, purpura caused by, 814. 
Snuffles, 242. 
Softening of brain, 1008. 



INDEX. 



1177 



Soil, influence of, in cholera, 177; in tuber- 
culosis, 208; in typhoid fever, 6. 

Solvent treatment of renal calculi, 896. 

Soor, 443. 

Sordes, 22. 

Sore throat, 448. 

Soya bread, 430. 

Spasm, congenital gastric, 495. 

Spasm, lock, in writer's cramp, 1108. 

Spasmodic wryneck, 1065. 

Spasms, in ergotism, 394; in hydrophobia, 
228; in hysteria, 1112; of face, 1055; of 
muscles, after facial paralysis, 1055; pro- 
fessional, 1107; saltatory, 1089. 

Spastic paraplegia of adults, 937; hereditary, 
940; hysterical, 941; ErUs syphilitic, 940; 
in children, 938; secondary, 941. 

Specific infectious diseases, 1. 

Specific treatment of typhoid fever, 46. 

Spectra, fortification, 1102. 

Speech (see Aphasia), 988. 

Speech, in adenoid vegetations, 456; in bul- 
bar paralysis, 932; in insular sclerosis, 959; 
in general paralysis, 962; in hereditary 
ataxia, 950; in paralysis agitans, 1078. 

Speech, scanning, in insular sclerosis, 959. 

Spes phthisica, 312. 

Spina bifida, involvement of cauda equina in, 
972. 

Spinal accessory nerve, paralysis of, 1063. 
Spinal apoplexy, 968. 
Spinal concussion, effects of, 1133. 
Spinal cord, diffuse and focal diseases of, 
964. 

Spinal cord, abscess of, 974; affections of 
blood-vessels of, 966; anaemia of, 966; 
chronic lepto-meningitis of, 957; compres- 
sion of, 970; congestion of, 966; embolism 
and thrombosis of vessels of, 966; endar- 
teritis of vessels of, 967; fissures in, 969; 
haemorrhage into, 968; lepto-meningitis of, 
954; localization of functions of, 905; 
pachymeningitis of, 953; sclerosis, primary 
combined, of, 949; syphilis of, 244; tuber- 
culosis of, 321; tumors of, 973; unilateral 
lesions of, 965. 

Spinal epilepsy, 937. 

Spinal irritation, 1125. 

Spinal membranes, haemorrhage into, 967. 

Spinal nerves, diseases of, 1067. 

Spinal neurasthenia, 1125. 

Spinal paralysis, atrophic, 942. 

Spirals, Ctirschmann's, 631, 633. 

Spirillum of relapsing fever, 54. 

Spiroehaete of Obermeier, 53. 

Splanchnoptosis, 541. 

Spleen, amyloid degeneration of, in syphilis, 
249; in tuberculosis, 298. 

Spleen, diseases of, 832; abscess of, 834; in- 
farct of, 834; tumors of, 834. 



Spleen, enlargement of, in congenital syph- 
ilis, 242, 244; in malaria, 207, 216. 

Spleen, excision of, in leukaemia, 809. 

Spleen, floating, 543, 833; pulsating, 805. 

Spleen, in ague, 208, 216; in anthrax, 226; in 
cirrhosis of liver, 572, 575; in Hodgkin's 
disease, 811; hydatid of, 372; in leukaemia, 
803, 805; in rickets, 435, 437; in acute tuber- 
culosis, 276; in typhoid fever, 10, 26; in 
typhus, 50. 

Spleen, rupture of, 833; in malaria, 208; in 

typhoid fever, 11. 
Splenectomy, statistics of, 809. 
Splenic anaemia, 834. 
Splenic fever, 224. 
Splenization of lung, 292, 635, 643. 
Splenomegaly, primitive, 834. 
Spondylitis deformans, 403. 
Sporozoa, 349; parasitic, 349. 
Spotted fever, 49, 101. 
Sprue, 511. 

Sputa, albuminoid, after aspiration of chest, 
678; alveolar cells in, 622, 635; amoeba coli 
in, 201; in cancer of lung, 664; in influenza, 
97; haematoidin crystals in, 580; in anthra- 
cosis, 654;. in asthma, 630; in bronchiecta- 
sis, 627; in acute bronchitis, 622; in chronic- 
bronchitis, 624; in putrid bronchitis, 625; 
in gangrene of lung, 661. 

Sputa, in phthisis, 300; in pneumonia, 118; 
in acute pulmonary tuberculosis, 275; 
prune-juice, 664; uric-acid crystals in, 411. 

Staphylococci, in diphtheria, 141; in endo- 
carditis, 702; in peritonitis, 597; in pneu- 
monia, 113; in pyaemia, 163; in septicaemia, 
162; in tonsillitis, 451. 

Status, epilepticus, 1097; hystericus, 1119. 

Status lymphaticus, 826; sudden death in, 
827. 

Stellwag's sign, 838. 
Stenocardia, 761. 

Stenosis, of aortic orifice, 715; of mitral 
orifice, 721; of pulmonary orifice, 727, 707; 
of tricuspid orifice, 726. 

Steppage gait, 1034. 

Stercoraceous vomiting, ~>34. 

Stercoral ulcers in colitis, 513. 

Stertor, in apoplexy, 1001. 

Stiff neck, 406. 

Stigmata, in hysteria, 1118; in purpura. 8i5. 
Stitch in side in pneumonia, 11.1; in pleurisy, 
668. 

Stoke8-Adama syndrome, 760. 

Stolidity of face in general paresis, 002. 

Stomach, acute cancer of. 493. 

Stomach, cancer of. 486; absence of free 
HC1 In, 491; diagnosis from gastric ulcer 
and chronic gastritis. 4;».">; haemorrhage in, 
490; vomiting in, 490. 

Stomach, dilatation of, 474; tetany in, 475. 



1178 



INDEX. 



Stomach, diseases of, 463. 

Stomach, atrophy of, 467; atony of, 500; 
chronic catarrh of, 466; erosions of, 468; 
foreign bodies in, 494; haemorrhage from, 
481, 495; hair tumors in, 494; neuroses of, 
497; non-cancerous tumors in, 494; tuber- 
culosis of, 319; ulcer of, 478; washing out 
of (lavage), 472. 

Stomatitis, 441; acute, 441; aphthous, 441; 
epidemic, 347; fetid, 442; follicular, 441; 
gangrenous, 444; mercurial, 444; neurotica 
chronica, 443; parasitic, 443; ulcerative, 
442; vesicular, 441; uraernic, 868. 

Stone-cutter's phthisis, 269, 652. 

Stools, of acute yellow atrophy, 552; of 
cholera, 179; of dysentery, 194, 197, 19S; 
of typhoid fever, 23; in hsematemesis, 497; 
of obstructive jaundice, 549. 

Strabismus, 1048. 

Strangulation of bowel, 531, 536. 

"'• Strawberry " tongue in scarlet fever, 78. 

Streptococci in diphtheria, 141; in empyema, 
671; in endocarditis, 702; in pneumonia, 
113; in peritonitis, 597; in pyaemia, 163; 
in scarlet fever, 77; in septicaemia, 162; in 
tonsillitis, 451. 

Streptococcus diphtheritis, 142. 

Streptococcus erysipelatos, 157. 

Streptococcus pyogenes in erysipelas, 157. 

Streptothrix actinomyces, 235. 

Strictures and tumors of the bowel, 533. 

Stricture of bile-duct, 560. 

Stricture of colon, cancerous, 533. 

Stricture of intestine, 533; after dysentery, 
200, 533; after tuberculous ulcer, 319. 

Stricture of oesophagus, 460. 

Stricture of pylorus, 494. 

Strongyloides intestinalis, 364. 

Strongylus duodenalis, 359. 

Strumitis, 836. 

Stuttering in mouth-breathers, 456. 

Styrian peasants, arsenical habit in, 391. 

Subclavian artery, murmur in and throbbing 
of, in phthisis, 308, 309. 

Subphrenic peritonitis, 600. 

Subsultus tendinum in typhoid fever, 29. 

Succussion, Hippocratic, 683. 

Succussion splash in dilated stomach, 476. 

Sudamina in typhoid fever, 17. 

Sudden death in angina pectoris, 762; in 
aortic insufficiency, 712; in coronary artery 
disease, 747; in enlarged thymus, 844; in 
pleural effusion, 671; in status lymphati- 
cu.s, 827; in typhoid fever, 40. 

Sudoral form of typhoid fever, 18. 

Sugar in the urine, 423. 

Sulphocyanides in excess in saliva in rheu- 
matism, 170. 
Sun-stroke, 395; after-effects of, 397. 
Suppression of urine, 850. 



Suppurative nephritis, 887. 

Suppurative pylephlebitis, 555, 578. 

Suppurative tonsillitis, 452. 

Suprarenal bodies, diseases of, 828; haemor- 
rhage into, 832; tuberculosis of, 832; 
tumors of, 832. 

Surgical kidney, 887. 

Suspension in compression paraplegia, 972. 

Sweating in acute rheumatism, 169; in ague, 
212; in diabetes, 423; in phthisis, 306; in 
pyaemia, 164; in typhoid fever, 18; in 
ulcerative endocarditis, 704; profuse, in 
rickets, 436; unilateral, in cervical caries, 
971; unilateral, in aneurism, 782. 

Sweating sickness, 346. 

Sydenham's chorea, 1079. 

Symmetrical gangrene, 1138. 

Sympathetic ganglia, in Addison's disease, 
829. 

Sympathetic nerve fibres (see Vasomotor). 

Symptomatic parotitis, 447. 

Syncope, fatal, in diphtheria, 151; in cardiac 
disease, 712, 750; in phthisis, 317; in pleu- 
ral effusion, 671. 

Syncope, local, 1137. 

Synovial rheumatism (see Gonorrhoea!, 
Rheumatism), 256. 

Synovitis, gonorrhoeal, 257. 

Synovitis, symmetrical, in congenital syph- 
ilis, 244. 

Syphilides, macular, 240; papular, 240; pus- 
tular, 240; squamous, 241; the late, 241. 

Syphilis, 238; accidental infection in, 238; 
acquired, 240; amyloid degeneration in, 
242; bone lesions of, 244; congenital, 242; 
early nerve lesions in, 245; gummata in, 
239; hereditary transmission of, 238; modes 
of infection in, 238; of brain and cord, 244, 
1020; of circulatory system, 250; of diges- 
tive tract, 249; of liver, 248; of lung, 247; 
orchitis in, 251; primary stage of, 240; 
prophylaxis of, 252; renal, 250; secondary 
stage of, 240; tertiary stage of, 241; vis- 
ceral, 244. 

Syphilis and dementia paralytica, 242, 246, 
961. 

Syphilis and locomotor ataxia, 242, 920. 

Syphilis haemorrhagica neonatorum, 243, 818. 

Syphilitic arteritis, 250. 

Syphilitic fever, 240. 

Syphilitic nephritis, 250. 

Syphilitic phthisis, 247. 

Syringomyelia, 975. 

Tabes, diabetic, 426. 

Tabes dorsalis (see Locomotor Ataxia), 

920; in chronic ergotism, 394. 
Tabes dorsalis spasmodique, 937. 
Tabes mesenterica, 2S3. 
Tache cerebrale, 17, 278. 



INDEX. 



1179 



Taches bleuatres, 18, 377. 

Tachycardia, 758, 838; neurasthenic, 1126; 
paroxysmal, 758. 

Tactile fremitus, in emphysema, 658; in 
pneumonia, 119; in pleural effusion, 668; in 
pneumothorax, 682; in pulmonary tubercu- 
losis, 307; at right apex, 307. 

Taenia echinococcus, 368, 370. 

Taenia elliptica, T. cucumerina, T. flavo- 
punctata, T. nana, T. Madagascariensis, 
T. confusa, 366. 

Taenia saginata or mediocanellata, 366. 

Taenia solium, 365. 

Tape-worms, 365; treatment of, 367. 

Taste, disturbances of, 1060; tests for sense 
of, 1060. 

Tea, neuritis caused by, 1035. 

Techomyza fusca, 379. 

Teeth, actinomyces in, 236; looseness of, in 
scurvy, 823; effects of stomatitis on, 445; 
erosion of, 445; Hutchinson's, 243, 445; of 
infantile stomatitis, 445. 

Teichopsia, 1102. 

Telegrapher's cramp, 1108. 

Temperature sense, loss of, in syringo- 
myelia, 975; in Morvan's disease, 975. 

Temperature, subnormal, in acute alcohol- 
ism, 380; in acute tuberculosis, 274; in 
apoplexy, 1001; in heat exhaustion, 395; in 
malaria, 209, 215; in pulmonary tubercu- 
losis, 306; in tuberculous meningitis, 279; 
in uraemia, 866. 

Temporal lobe, tumors of, 1022. 

Temporo-sphenoidal lobe, centre for hearing 
in, 1056. 

Tender points in neuralgia, 1104; in neuras- 
thenia, 1123. 
Tender toes, in typhoid fever, 29. 
Tendon-reflexes (see Reflexes). 
Terminal infections, 165. 
Tertian ague, 212. 

Testes, tuberculosis of, 326; syphilis of, 251 

(see also Orchitis). 
Tetanus, 230; bacillus of, 231; neonatorum, 

230. 

Tetanus, cephalic, 232. 

Tetany, 1109; after thyroidectomy, 1110; epi- 
demic or rheumatic, 1109; in dilatation of 
the stomach, 475, 1110; in myxoedenia, 
1110; in typhoid fever, 30. 

Tetrodon, poisoning by, 394. 

Therapeutic test in syphilis, 251. 

Therapy, serum, in plague, 192. 

Thermic fever, 395. 

Thermic sense, loss of, in syringomyelia, 
975. 

Third nerve, diseases of, 1045. 

Third nerve, recurring paralysis of, 1046; 

signs of paralysis of, 1046. 
Thotn sen's disease, 1149. 



Thoracic duct, tuberculosis of, 273. 
Thorax, deformity of, in mouth-breathers, 

455; in rickets, 436. 
Thorax in emphysema, 658; in phthisis, 263, 

306. 

Thorn-headed worms, 365. 

ThovnwaldV s disease, 457. 

Thread-worm, 353. 

Throbbing aorta, 786, 1126. 

Thrombi in heart, 723; in pneumonia, 114. 

Thrombi in veins in typhoid fever, 21. 

Thrombi, marantic, 1015. 

Thrombosis of cerebral arteries, 1008; of 
cerebral sinuses, 1015; of cerebral veins, 
1015; of portal vein, 554. 

Thrush, 443. 

Thymic asthma, 618, 844. 

Thymus gland, diseases of, 843; abscess of, 

845; tumors of, 845; persistence of, 844; 

enlargement of, 844; sudden death in, 844. 
Thymus gland, in acromegaly, 1143; an! 

exophthalmic goitre, 845. 
Thyroid abscess, 836. 

Thyroid extract, administration of, 843, 
1111. 

Thyroid gland, aberrant or accessory tumors 
of, 836; abscess of, 836; absence of, in 
cretins, 840; adenomata of, 836; cancer of, 
836; in exophthalmic goitre, 838; in goitre, 
836; in myxoedenia, 842; sarcoma of, 83G; 
tumors of, 836. 

Thyroid gland, diseases of, 835. 

Thyroidism, 843. 

Tic convulsif, 1055. 

Tic douloureux, 1105. 

Ticks, 376. 

Tinnitus aurium, 1057. 

Tintement metallique, 738. 

Tobacco, influence of, on the heart, 764. 

Tongue, atrophy of, 10(56; eczema of, 445; 
geographical, 445; in bulbar paralysis, 932; 
spasm of, 1067; tuberculosis of, 318; uni- 
lateral hemiatrophy of, 1067. 

Tongue, tremor of, in general paresis, 962; 
ulcer of fraenum in whooping-cough, 93. 

Tonsillitis, 451; acute, 451; albuminuria in, 
452; endocarditis in, 452; in the newly mar- 
ried, 451. 

Tonsillitis, chronic, 454; follicular, 451: 
lacunar, 451; suppurative, 4f>2; and rheu- 
matism, 451. 

Tonsils, abscess of. 452; calculi of. 45H; 
cheesy masses in, 456; enlarged, 454; tuber- 
culosis of. 318. 

Tonsils, diseases of. 451. 

Tophi, 411. 

Topical diagnosis, spinal, net; cerebral, 979. 
Torticollis, 106, 1064: congenital, 1064; facial 

asymmetry in, 10(14 ; spasmodic;, 1065. 
Toxic gastritis, 465. 



1180 



INDEX. 



Toxines, in septicaemia, 161. 

Tracheal tugging, 780. 

Traction aneurism, 777. 

Trance in hysteria, 1113, 1119. 

Traube's semilunar space, 669. 

Trauma as a factor, in delirium tremens, 

382; in neurasthenia, 1132; in pneumonia, 

109; in tuberculosis, 270. 
Trematodes, diseases caused by, 351. 
Trembles in cattle, 344. 

Tremor, alcoholic, 381, 1079; in Graves' dis- 
ease, 839; hereditary, 1079; hysterical, 
1079, 1115; in exophthalmic goitre, 839; 
lead, 389; in paralysis agitans, 1077; 
Rendu' s type of, 1115; senile, 1079; simple, 
1079; toxic, 1079; volitional, in insular 
sclerosis, 959. 

Trichina spiralis, 354; distribution of, 355; 
statistics of, in American hogs, 355; in 
Germany, 355; modes of infection, 356. 

Trichiniasis, 354; epidemics of, 356; prophy- 
laxis of, 359. 

Trichocephalus dispar, 364. 

Trichomonas vaginalis, 351; T. hominis, 351. 

Trichter-brust, 307, 455. 

Tricuspid orifice, stenosis of, 726. 

Tricuspid valve, disease of, 725; insufficiency 
of, 725. 

Trigeminus (see Fifth Nerve). 

Trismus, neonatorum, 230; hysterical, 1114. 

Trommer's test, 423. 

Trophic disorders, 1137. 

Tropical dysentery, 195. 

Trousseau's symptom, in tetany, 1110. 

Tubal pregnancy, ruptured, simulating peri- 
tonitis, 600. 

Tubercle bacilli, 259, 301. 

Tubercle, diffuse infiltrated, 272; miliary, 
270, 295; changes in, 271; structure of, 270; 
nodular, 270. 

Tubercles, miliary, in chronic phthisis, 295. 

Tubercula dolorosa, 1037. 

Tuberculin, 261; test, 258; treatment, 335. 

Tuberculosis, acute, 273; general or typhoid 
form, 274; meningeal form, 276; pulmonary 
form, 275. 

Tuberculosis, 258; bacillus of, 259, 301; 
changes produced by bacillus, 270; chronic 
miliary, 295; of circulatory system, 327; 
conditions influencing infection, 267; con- 
genital, 262; dietetic treatment of, 335; 
distribution of the tubercles in, 270; dura- 
tion of pulmonary form of, 329; hereditary 
transmission of, 262; individual prophy- 
laxis in, 330; infection by meat, 267; in- 
fection by milk, 267; infection by inhala- 
tion, 265; inoculation of, 264; in infants, 
316; in old age, 316; medicinal treatment 
of, 336; modes of death in pulmonary, 317; 
modes of infection in, 262; natural or spon- 



taneous, cure of, 331; of alimentary canal, 
317; of brain and cord, 321; of Fallopian 
tubes, 326; of genito-urinary system, 322; 
of kidneys, 324; of liver, 320; of lymphatic 
system,- 280; of mammary gland, 327; of 
ovaries, 326; of pericardium, 285; of peri- 
tonaeum, 286; of pleura, 284; of prostate, 
326; of serous membranes, 284; of testes, 
326; of ureters and bladder, 325; of uterus, 
326; of vesiculae seminales, 326; pregnancy, 
influence of, in, 329; prophylaxis in, 330; 
pseudo-, 262; pulmonary, 289; and typhoid 
fever, 33; and valvular disease of heart, 
316. 

TufnclVs treatment of aneurism, 784. 

Tumors of brain, 1020. 

Tunnel anaemia, 360. 

Twists and knots in the bowel, 533. 

Tympanites, in intestinal obstruction, 535; 
in peritonitis, 598; in tuberculous perito- 
nitis, 287; in typhoid fever, 24; as a cause 
of sudden heart failure, 545. 

Typhlitis, 519. 

Typhoid fever, 1; abortive form, 33; afebrile, 
17, 34; ambulatory form, 14, 34; anaemia 
in, 19; and tuberculosis, 33; bacillus of, 4; 
chills in, 17; circulatory system in, 19; 
diabetes in, 33; diarrhoea in, 23; digestive 
system in, 22; Ehrlich's reaction in, 30; 
erysipelas in, 33; grave form of, 34; 
haemorrhage in, 23; hemorrhagic, 34; his- 
torical note on, 1; immunity from, 3; in 
the aged, 35; in children, 34; in the foetus, 
35; in pregnancy, 35; laparotomy in, 47; 
liver in, 11, 26; Maidstone epidemic of, 6; 
meteorism in, 24; mild form, 33; modes of 
conveyance of, 5; nervous system in, 12, 
28; noma in, 33, 35; osseous system in, 32; 
oysters and, 6; parotitis in, 22; perforation 
of bowel in, 10, 25; peritonitis in, 25, 47; 
post-typhoid variations of temperature in, 
16; prognosis of, 39; prophylaxis of, 40; 
pyuria in, 31; relapses in, 35; renal system 
in, 30; respiratory system in, 27; serum 
therapy in, 46; skin rashes in, 17; spleen 
in, 26: tender toes in, 29; tetany in, 30: 
varieties of, 33; WidaVs reaction in # typhoid 
fever, 37. 

Typhoid gangrene, 12, 22; septicaemia, 32. 
Typhoid spine, 32. 

Typhoid state in obstructive jaundice, 550; 

in acute yellow atrophy, 552. 
Typho-malarial fever, so-called, 39, 214. 
Typhotoxin. 8. 

Typhus fever, 49; complications and sequelae 

of, 52. 
Typhus siderans, 52. 
Tyrosin, 552. 
Tyrotoxicon, 393. 
Tyrotoxismus, 393. 



INDEX. 



11S1 



Ulcer, cancerous, of intestine, 513; gastric, 
478; of duodenum, 478; of bowel in dysen- 
tery, 196, 197, 198; in typhoid fever, 9. 

Ulcer of mouth, 442; in the new-born, 443; 
in nursing women, 443; of palate in in- 
fants, 443. 

Ulcer, peptic, 478; perforating, of foot, in 

tabes, 925; in diabetes, 425. 
Ulcerative endocarditis, 699. 
Ulcers, Parrot's, 443. 
Ulnar nerve, affections of, 1071. 
Uncinaria duodenalis, 359. 
Unconsciousness (see Coma). 
Undulant fever, 219. 

Uraemia, 865; cerebral manifestations of, 
866; coma in, 867; convulsions in, 866; 
diagnosis from apoplexy, 868; dyspncea in, 
867; headache in, 867; in Bright's disease, 
884; latent, 851; local palsies in, 867; 
oedema of brain in, 997; stomatitis in, 868; 
theories of, 865. 

Urate (lithate) of soda in gout, 408. 

Urates in the urine, 860. 

Urates (lithates), amorphous, 860. 

Ureter, blocking of, 850; mucous cysts of, 
350; obstructed by calculi, 893; psorosper- 
miasis of, 350; tuberculosis of, 325. 

Urethritis, gouty, 415. 

Uric acid, calculus, 892; deposition of, 860; 
in gout, 408; in urine, 860; " showers," 
415. 

Uric-acid diathesis (see Lith^emia), 860. 
Uric-acid headache, 415. 
Uric-ackl theory of gout, 408. 
Urinary calculi, 892. 

Urine, anomalies of the secretion of, SCO. 

Urine, density of, in acute Bright's disease, 
870; in chronic Bright's disease, 880; in 
diabetes, 423; in diabetes insipidus, 433. 

Urine, hsemoglobin in, 852. 

Urine, in acute yellow atrophy of liver, 552; 
in grave anaemia, 799; in cholera, 179; in 
diabetes insipidus, 433; in diabetes mel- 
litus, 423; in diphtheria, 150; in erysipelas, 
159; in gout, 411, 413, 415; in jaundice, 549; 
in melanotic sarcoma, 863; in pneumonia, 
122; in acute pulmonary tuberculosis, 312; 
in typhoid fever, 30; oxalates in, 861 ; pus 
in, 858. 

Urine, quantity of, in chronic Bright's dis- 
ease, 880; in diabetes insipidus, 433; in 
diabetes mellitus, 423; in intestinal ob- 
struction, 535. 

Urine, retention of, in typhoid fever, 30. 

Urine, suppression of. 850; treatment of, 851; 
in cholera, 179; in acute nephritis, S70; in 
scarlet fever, 80; iu acute intestinal ob- 
struction, 535; obstructive suppression, 
894. 

Urine, tests for albumin in, 856; biliary pig 



ment in, 549; blood in, 852; albumoses in, 
857; peptones in, 857. 
Urobilin, increase of, in pernicious anaemia, 
799. 

Uro-genital tuberculosis, 522. 

Urticaria, after tapping of hydatid cysts, 
372; epidemica, 379; giant form (see Neu- 
rotic CEdema), 1141; with purpura, 815; 
in small-pox, 60; in typhoid fever, 17. 

Uterus, tuberculosis of, 326. 

Uvida, oedema of, 448; infarction of, 448; 
816. 

Vaccination, 68; mark, 70; technique of, 73; 
rashes, 71; ulcers, 71; value of, 73. 

Vaccine, antityphoid, 41. 

Vaccine lymph, choice of, 72. 

Vaccinia, 68; bacteriology of, 70; general- 
ized, 71. 

Vaccino-syphilis, 71. 

Vagabond's discoloration, 377, 831. 

Valvular disease of heart, 707; and tubercu- 
losis, 316. 

Varicella, 74; haemorrhagic, 75. 

Varicella bullosa, 75; escharotica, 75. 

Varices, oesophageal, in cirrhosis of liver, 
459. 

Variola, 56; haemorrhagica, 59, 62, 63; vera, 
59. 

Variola haemorrhagica pustulosa, 62, 63. 

Variola sine eruptione, 64. 

Varioloid, 59, 63. 

Vaso-motor disorders, 1137. 

Vaso-motor disturbances in caries, 971; in 
chronic pleurisy, 680; in exophthalmic goi- 
tre, 839; in hemicrania, 1103; in myelitis, 
977; in neuralgia, 1104. 

Veins, cerebral, thrombosis in, 1015; dias- 
tolic collapse of, 697; pulsation in, 311, 
1083, 1126; sclerosis of, 773. 

Vena cava, twist in, 668. 

Vena cava, superior, perforation of, by aneu- 
rism, 778, 788. 

Venereal disease, 238. 

Venesection (see Bloodletting). 

Venous pulse, 311, 1083, 1126. 

Ventricles of brain, dilatation of (hydro- 
cephalus), 1028; puncture of, 1030. 

Ventricular haemorrhage, 999. 

Verruca necrogenica, 264. 

Vertebrae, caries of, 970: cervical, caries of, 
971. 

Vertebral artery, obstruction of. 1010. 
Vertigo, auditory, 1058; cerebellar, 986; in 

artorio-sclorosis. 775; in brain tumor, 1021; 

gastric. 469; labyrinthine, 1058; endemic 

paralytic, 1059. 
Vesiculffi serainales, tuberculosis of. 326. 
Vicarious, epistaxis. (il4: haemoptysis, 637. 
Virus firr, 229. 



1182 



INDEX. 



Visceroptosis, 541. 
Vitiligoidea, 549. 

Vocal fremitus, 119, 668; resonance, 120, 670. 
Voice (see Speech). 

Voice, alteration of, in mouth-breathers, 456. 
Volitional tremor, 959. 
Volvulus, 533, 537. 

Vomica, 296; signs of, in phthisis, 309. 

Vomit, black, 186; coffee-ground, 490. 

Vomiting, in Addison's disease, 830; in 
Bright- s disease, 881; in cerebral abscess, 
1026; in cerebral tumor, 1021; in chronic 
obstruction of intestines, 535; in chronic 
ulcerative phthisis, 311; in gall-stone colic, 
564; in gastric cancer, 490; in gastric ulcer, 
481; in acute obstruction of intestines, 534; 
in tuberculous meningitis, 278; in migraine, 
1103; in peritonitis, 598; in small-pox, 59; 
nervous, 499; primary periodic, 499; sterco- 
raceous, 534; ursemic, 867. 

von Noorden's dietary in obesity, 440. 

Vulvitis, ulcerative, in measles, 87. 

Wall-paper, poisoning by arsenic in, 390. 

Wart-pox, 63. 

Warts, post-mortem, 264. 

Washing out stomach, 472, 477. 

Water-hammer pulse, 714. 

Water, infection by, in diphtheria, 138; in 

cholera, 177; in typhoid fever, 5. 
" Water on the brain," 276. 
Weber, syndrome of, 279, 1004, 1023. 
WeiVs disease, 344. 
Wcrlhoff's disease, 816. 

Wernicke's hemiopic pupillary inaction, 1044. 



Wet-pack, 84. 
Whip-worm, 304. 

White softening of the brain, 1009. 
White thrombi in heart, 723. 
Whooping-cough, 92. 

Winckel's disease (see Epidemic Hjbm-o- 

GLOBINUKIA OF THE NEW-BORN), 243, 818, 

853. 

" Winged scapulae," 307. 
Wintrich's sign, 309. 
Woillcz, maladic de, 634. 
Wool-sorter's disease, 224, 226. 
Word-blindness, 992. 
Word-deafness, 992. 

Wormian bones in hydrocephalus, 1029. 

Worms (see Parasites). 

Wounds of the heart, 754. 

Wrist-drop, 1071; in lead-poisoning, 388. 

Writer's cramp, 1107. 

Wryneck, 1064; spasmodic, 1065. 

Xanthelasma, 549. 
Xanthine calculi, 892. 
Xanthomata, 425, 549, 565. 
Xanthopsia, 353. 
Xerostomia, 447. 

Yellow fever, 182; bacteriology of, 184: epi- 
demics of, 182. 
Yellow softening of brain, 1009. 
Yellow vision, 353. 

Zinc, peripheral neuritis from, 1035. 
Zona, 1106. 



THE END. 



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